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Maine 2–100 Plan guide

The health of business, well planned.

Plans effective October 1, 2012 For businesses with 2-100 eligible employees www.aetna.com

64.10.302.1-ME (6/12) Team with Aetna for the health of your business Introducing a new suite of products and services designed specifically for companies with 2 to 100 eligible employees. 64.44.302.1-ME (6/12) 64.44.302.1-ME 64.43.302.1-ME (6/12)

Health benefits and health insurance, dental benefits/dental insurance, life insurance and disability insurance plans/policies are offered, underwritten or administered by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna). 2 You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business.

Aetna is committed to helping employers build healthy businesses. In this guide: In today’s rapidly changing economy, we recognize the need for 5 Small-business commitment less expensive, less complex health plan choices. Now, Aetna offers a variety of newly streamlined medical and dental 5 Benefits for every stage of life

64.44.302.1-ME (6/12) 64.44.302.1-ME benefits and insurance plans to provide more affordable options 6 Medical overview and to help simplify plan selection and administration. 8 Managing health care expenses 10 Medical plan options 24 Dental overview 26 Dental plan options

64.43.302.1-ME (6/12) 33 Life & disability overview 36 Life & disability plan options 38 Underwriting guidelines 48 Product specifications 58 Limitations and exclusions

3 Employers and their employees can benefit from… Simplicity • Affordable plan options We know that the health of your business is your top priority. • Online self-service tools and capabilities Aetna’s streamlined plans and variety of services make it easier for • Enhanced services for consumer-directed health plans you to focus on your business by simplifying administration and management. • 24-hour access to Employee Assistance Program services • Preventive care covered 100% Aetna makes it easy to manage health insurance benefits with simplified enrollment, billing and claims processing so you can • Aetna disease management and wellness programs focus on what matters most. With Aetna, we know it’s about... Trust Options We work hard to provide health plan solutions you can trust. Our account executives, underwriters and customer service We provide a variety of health plan options to help meet your representatives are committed to providing businesses and employees’ needs, including medical, dental, disability and their employees with service they can trust. life insurance. And, with access to a wide network of health care providers, Aetna resources are designed to fortify the health you can be sure that employees have options in how they of your business access their health care. • Track medical claims and take advantage of online services with Medical plans your Aetna Navigator® secure member website. It features automated enrollment, personal health records and printable • HSA-compatible plans temporary member ID cards. • Hospital deductible plans • Get real cost and health information to help make the right care • Up-front deductible plans decision with an online Cost of Care Estimator. Dental plans • Manage health records online with the Personal Health Record. • PPO • Use the Aetna Health ConnectionsSM Disease Management • Indemnity Program, which provides personal support to members to help them manage their conditions. Life and disability plans* • Leverage 24/7 access to a nurse to help with personal • Basic life health-related questions. • Supplemental life • Help members work toward health goals with wellness initiatives, ® • AD&D Ultra® such as the Simple Steps to a Healthier Life online program. • Supplemental AD&D Ultra® • Take advantage of discount programs for vision, dental, and general health care that encourage use of plan offerings. • Dependent life • Short-term disability • Long-term disability

*For groups 51 to 100 please consult your sales representative for a plan design to meet your group needs. 4 Aetna is committed to the health of your business

We understand that your business has unique needs. That’s why we have streamlined our plan options for employers with 2 to 100 employees. We are committed to providing you with value and quality you can count on. Our variety of products and services allows you to focus on the health of your business.

Aetna’s health plan options are designed with the Health insurance benefits for every stage of life health of your business in mind For young individuals and couples without children… Basic plans • Lower monthly payments • Modest out-of-pocket costs • Basic benefits for your employees • Quality preventive care • Limit the expense to your business • Prescription drug coverage • Allow employees to buy up and share more of the cost • Financial protection --ME HNOnly 1000 HD 20/35 --ME HNOnly 3000 UD 25/45 HSA-compatible plans --ME PPO 2500/80 Hospital deductible plans Up-front deductible plans Value plans For married couples and single parents with teens and • Encourage employee responsibility in their health care decisions college-aged children… • Tools and resources to support consumerism • Checkups and care for injuries and illness • Innovative plan design • Preventive care and screenings that promote a healthy lifestyle --ME HNOnly 3000/90 HSA Compatible • National network of health care providers --ME HNOnly 5000/90 HSA Compatible HSA-compatible plans --ME PPO 2500/80 HSA Compatible Hospital deductible plans

Standard plans For married couples and single parents with young • Standard benefits plans children or teens… • Limit the financial impact on employees • Lower fees for office visits --ME HNOnly 500 HD 20/30 51+ • Lower monthly payments --ME PPO 1000/90 51+ • Caps on out-of-pocket expenses --ME PPO 1500/80 • Quality preventive care for the entire family Hospital deductible plans

For men and women 55 years of age and over with no children at home… • Financial security • Quality prescription drug coverage • Hospital inpatient/outpatient services • Emergency care HSA-compatible plans Hospital deductible plans Up-front deductible plans

5 Aetna Medical Overview At Aetna, we are committed to putting the employee at the center of everything we do. You can count on Aetna to provide health plans that help simplify decision making and plan administration so you can focus on the health of your business.

6 Medical Overview

Maine Provider network All medical plans are available in the following counties: Androscoggin Hancock Oxford Somerset Aroostock Kennebec Penobscot Waldo Cumberland Knox Piscataquis Washington Franklin Lincoln Sagahadoc York

Product Product PCP Referrals DocFind® Name Description Required Required Plan Name

PPO PPO plan members can see any recognized provider for No No Open Choice® covered services without a referral. Each time members seek PPO health care, they have the freedom to choose either network providers at lower out-of-pocket costs, or non-network providers at higher out-of-pocket costs.

Aetna Health Aetna Health Network Only (HNOnly) is a health maintenance Optional No Aetna Health Network OnlySM organization plan that uses a network of participating Network OnlySM (HNOnly) providers. Each family member may select a primary care (Open Access) physician (PCP) participating in the Aetna network to provide routine and preventive care and help coordinate the member’s total health care. Members never need a referral when visiting a participating specialist for covered services. Only services rendered by a participating provider are covered, except for emergency or urgently needed care.

Traditional Choice This indemnity plan option is available for employees who live No No N/A (TC) outside the plan’s network service area. Members coordinate their own health care and may see any recognized provider for covered services without a referral.

7 Aetna High-Deductible HSA-Compatible Health No Cost Health Incentive Credit† Network Only and PPO plans Members can earn $50 in just a few simple steps Health Network Only and PPO health plans are compatible with Members earn a $50 credit toward their out-of-pocket expenses a health savings account (HSA). HSA-compatible plans provide when they: integrated medical and pharmacy benefits. Preventive care services are exempt from the deductible. • Complete or update their Health Assessment on Simple Steps To A Healthier Life. HSAs provide employers and their qualified employees with an affordable tax-advantaged solution that allows them to better • Complete one online wellness program. manage their qualified medical and dental expenses. If the employee’s spouse is covered under the plan, he or she is • Employees can build a savings fund to help cover their future also eligible for the same incentive credit. So a family could save medical and dental expenses. HSAs can be funded by the $100 in out-of-pocket expenses each year. Incentive rewards will employer or employee and are portable. be credited toward the deductible and maximum out-of-pocket limit. This program is included at no additional cost, except with • Fund contributions may be tax deductible (limits apply). HSA-compatible plans. • When funds are used to cover qualified out-of-pocket medical and dental expenses, they are not taxed. COBRA administration • It is completely at the discretion of the employer or employee Aetna COBRA administration offers a full range of notification, whether or not to establish an HSA. documentation and record-keeping processes that can help Note: Employers and employees should consult with their tax employers manage the complex billing and notification processes advisor to determine eligibility requirements and tax advantages required for COBRA compliance, while also helping to save them for participation in the HSA plan. time and money.

Health Savings Account (HSA)

No set-up or administrative fees The Aetna HealthFund HSA, when coupled with an HSA-compatible high-deductible health benefits and health insurance plan, is a tax-advantaged savings account. Once enrolled, either the employee or the employer can make account contributions. The HSA can be used to pay for qualified expenses tax free.

Member’s HSA plan • You own your HSA • Contribute tax free • You choose how and when to use your dollars • Roll it over each year and let it grow • Earns interest, tax free

Today • Use for qualified expenses with tax-free dollars

Future • Plan for future and retiree health-related costs

High-deductible health plan • Eligible in-network preventive care services will not be subject to the deductible • You pay 100% until deductible is met, then only pay a share of the cost • Meet out-of-pocket maximum, then plan pays 100%

†Not applicable to HSA-compatible plans. 8 Section 125 Cafeteria Plans and Section 132 Transit Reimbursement Accounts Administrative Fees Employees can reduce their taxable income, and employers can pay less in payroll taxes. There are three ways to save: Fee description Fee HSA Premium-Only Plans (POP) Initial set-up $0 Employees can pay for their portion of the group health insurance expenses on a pretax basis. First-year POP fees Monthly fees $0 are waived with the purchase of medical coverage with five or POP more enrolled employees. Initial set-up* $175 Renewal $100 Flexible Savings Account (FSA) HRA and FSA** FSAs give employees a chance to save for health expenses with pretax money. Health care spending accounts allow Initial set-up* employees to set aside pretax dollars to pay for out-of-pocket 1–25 employees $350 expenses as defined by the IRS. Dependent care spending 26–50 employees $450 accounts allow participants to use pretax dollars to pay child 51–100 employees $550 or elder care expenses. Renewal fee Transit Reimbursement Account (TRA) 1–25 employees $225 TRAs allow participants to use pretax dollars to pay 26–50 employees $275 transportation and parking expenses for the purpose of 51–100 employees $325 commuting to and from work. Monthly fees*** $5.25 per participant Additional set-up fee for “stacked” plans $150 Group Situs (those electing an Aetna HRA and FSA simultaneously) Medical and dental benefits and rates are based on the Participation fee for “stacked” participants $10.25 per participant group’s headquarters location, subject to applicable state laws. Eligible employees who live or work in CT and ME (the situs Minimum fees region) will receive the same rates and benefits as the 1–25 employees $25 per month minimum headquarters location. 26–100 employees $50 per month minimum TRA Multi-State Solution Annual fee $350 We offer a multi-state solution to make it easier for businesses Transit monthly fees $4.25 per participant like yours to do business with us. We believe it brings more Parking monthly fees $3.15 per participant consistency across medical benefits offerings to employers with employees in multiple locations. COBRA (federal) Annual fee Employers based in Maine can offer ME PPO plans to their 20–50 employees $100 employees who live and work outside of the “situs” region. The situs region comprises Maine and Connecticut. 51–100 employees $175 The rates and benefits will match those offered in Maine. Per employee per month If the out-of-situs employee lives in a non-network area, the 20 – 50 employees $0.88 employee will be enrolled in an indemnity plan. Plan sponsors will 51 – 100 employees $1.02 need to continue to meet underwriting guidelines, subject to all Initial notice fee $1.50 per notice applicable state laws. (includes notices at time of implementation and during In all instances, extraterritorial benefits that may apply on any of ongoing administration) the out-of-situs employees will be implemented where required. Monthly fee $0.88 per employee

*Nondiscrimination testing provided annually after open enrollment for POP and FSA only. Additional off-cycle testing available at employer request for $100 fee. Nondiscrimination testing only available for FSA and POP products. **Aetna FSA pricing is inclusive for POP. Debit cards are available for FSA only. Contact Aetna for further information. ***For HRA, if the employer opts out of Streamline, the fee is increased $1.50 per participant. For FSA, the debit card is available for an additional $1 per participant per month. Mailing reimbursement checks direct to employee homes is an additional $1 per participant per month. Aetna HRAs are subject to employer-defined use and forfeiture rules. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information subject to change. Aetna reserves the right to change any of the above fees and to impose additional fees upon prior written notice. 9 Aetna 2-100 Health Network Only (HNOnly) HSA Compatible† Plan Options*

ME HNOnly ME HNOnly ME HNOnly ME HNOnly 2500/90 3000/90 4000/90 5000/90 Plan Options 2-100 HSA Compatible† HSA Compatible† HSA Compatible† HSA Compatible†

Member Benefits In-network In-network In-network In-network

Member Coinsurance 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Calendar Year Deductible** $2,500 Individual $3,000 Individual $4,000 Individual $5,000 Individual (Embedded) $5,000 Family $6,000 Family $8,000 Family $10,000 Family

Calendar Year Out-of-Pocket Maximum** $3,500 Individual $5,000 Individual $5,500 Individual $ 6,050 Individual (Embedded) $7,000 Family $10,000 Family $11,000 Family $12,100 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Primary Care Physician Office Visit 0% after deductible 0% after deductible 0% after deductible 0% after deductible

Specialist Office Visit 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; 0%; 0%; 0%; Routine Gyn Exams, Routine Mammograms, Routine deductible waived deductible waived deductible waived deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months $100 every 24 months $100 every 24 months

Aetna VisionSM Discount Program Included Included Included Included

Outpatient Services 10% after deductible 10% after deductible 10% after deductible 10% after deductible (Lab and X-ray)

Outpatient Complex Imaging 10% after deductible 10% after deductible 10% after deductible 10% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Outpatient Surgery 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Emergency Room 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Urgent Care 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Outpatient Rehabilitation Therapy 10% after deductible 10% after deductible 10% after deductible 10% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy)

Chiropractic Services 10% after deductible 10% after deductible 10% after deductible 10% after deductible (36 visits per calendar year)

Durable Medical Equipment 10% after deductible 10% after deductible 10% after deductible 10% after deductible ($2,500 calendar year maximum)

Prescription Drugs††

Retail and Mail Order (MOD) After integrated After integrated After integrated After integrated (1x copay up to a 30-day retail supply medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy 2x copay up to 31- to 90-day retail/MOD supply) deductible is met, deductible is met, deductible is met, deductible is met, $10/$35/$50 $10/$35/$50 $10/$35/$50 $10/$35/$50

Specialty Care Drugs After integrated After integrated After integrated After integrated medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy deductible is met, deductible is met, deductible is met, deductible is met, 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 10 Aetna 51-100 Health Network Only (HNOnly) HSA Compatible† Plan Options*

ME HNOnly ME HNOnly ME HNOnly ME HNOnly 2500/90 3000/90 4000/90 5000/90 HSA Compatible† HSA Compatible† HSA Compatible† HSA Compatible† Plan Options 51-100 51+ 51+ 51+ 51+

Member Benefits In-network In-network In-network In-network

Member Coinsurance 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Calendar Year Deductible** $2,500 Individual $3,000 Individual $4,000 Individual $5,000 Individual (Embedded) $5,000 Family $6,000 Family $8,000 Family $10,000 Family

Calendar Year Out-of-Pocket Maximum** $3,500 Individual $5,000 Individual $5,500 Individual $6,050 Individual (Embedded) $7,000 Family $10,000 Family $11,000 Family $12,100 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Primary Care Physician Office Visit 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Specialist Office Visit 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; 0%; 0%; 0%; Routine Gyn Exams, Routine Mammograms, Routine deductible waived deductible waived deductible waived deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months $100 every 24 months $100 every 24 months

Aetna VisionSM Discount Program Included Included Included Included

Outpatient Services 10% after deductible 10% after deductible 10% after deductible 10% after deductible (Lab and X-ray)

Outpatient Complex Imaging 10% after deductible 10% after deductible 10% after deductible 10% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Outpatient Surgery 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Emergency Room 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Urgent Care 10% after deductible 10% after deductible 10% after deductible 10% after deductible

Outpatient Rehabilitation Therapy 10% after deductible 10% after deductible 10% after deductible 10% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy)

Chiropractic Services 10% after deductible 10% after deductible 10% after deductible 10% after deductible (36 visits per calendar year)

Durable Medical Equipment 10% after deductible 10% after deductible 10% after deductible 10% after deductible ($2,500 calendar year maximum)

Prescription Drugs††

Retail and Mail Order (MOD) After Integrated After Integrated After Integrated After Integrated (1x copay up to a 30-day retail supply medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy 2x copay up to 31- to 90-day retail/MOD supply) deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, $10/$35/$50 $10/$35/$50 $10/$35/$50 $10/$35/$50

Specialty Care Drugs After Integrated After Integrated After Integrated After Integrated medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 11 Aetna 2-100 Health Network Only (HNOnly) Plan Options*

ME HNOnly ME HNOnly ME HNOnly ME HNOnly ME HNOnly Plan Options 2-100 1000 HD 20/35 2000 UD 25/45 3000 UD 25/45 4000 UD 25/50 7500 UD 30/50

Member Benefits In-network In-network In-network In-network In-network

Member Coinsurance N/A 30% after 30% after 30% after 30% after deductible deductible deductible deductible

Calendar Year Deductible** $1,000 Individual $2,000 Individual $3,000 Individual $4,000 Individual $7,500 Individual (Embedded) $2,000 Family $4,000 Family $6,000 Family $8,000 Family $15,000 Family

Calendar Year Out-of-Pocket Maximum** $2,500 Individual $4,000 Individual $5,000 Individual $6,000 Individual $9,500 Individual (Embedded) $5,000 Family $8,000 Family $10,000 Family $12,000 Family $19,000 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited Unlimited

Primary Care Physician Office Visit $20 copay; $25 copay; $25 copay; $25 copay; $30 copay; deductible waived deductible waived deductible waived deductible waived deductible waived

Specialist Office Visit $35 copay; $45 copay; $45 copay; $50 copay; $50 copay; deductible waived deductible waived deductible waived deductible waived deductible waived

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, $0 copay; $0 copay; $0 copay; $0 copay; $0 copay; Routine Gyn Exams, Routine Mammograms, Routine deductible waived deductible waived deductible waived deductible waived deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 $100 every 24 $100 every 24 $100 every 24 $100 every 24 months months months months months

Aetna VisionSM Discount Program Included Included Included Included Included

Outpatient Services $35 copay; $35 copay after $45 copay after $50 copay after $50 copay after (Lab and X-ray) deductible waived deductible deductible deductible deductible

Outpatient Complex Imaging 20%; 30% after 30% after 30% after 30% after (MRA/MRS, MRI, PET and CAT scans) deductible waived deductible deductible deductible deductible

Inpatient Hospital 20% after 30% after 30% after 30% after 30% after deductible deductible deductible deductible deductible

Outpatient Surgery 20% after 30% after 30% after 30% after 30% after deductible deductible deductible deductible deductible

Emergency Room $150 copay; $150 copay; $200 copay; $200 copay; $200 copay; (Copay waived if admitted) deductible waived deductible waived deductible waived deductible waived deductible waived

Urgent Care $150 copay; $150 copay; $200 copay; $200 copay; $200 copay; deductible waived deductible waived deductible waived deductible waived deductible waived

Outpatient Rehabilitation Therapy $35 copay; 30% after 30% after 30% after 30% after (50 combined visits per calendar year for physical, deductible waived deductible deductible deductible deductible occupational and speech therapy)

Chiropractic Services $35 copay; 30% after 30% after 30% after 30% after (36 visits per calendar year) deductible waived deductible deductible deductible deductible

Durable Medical Equipment 20%; 30% after 30% after 30% after 30% after ($2,500 calendar year maximum) deductible waived deductible deductible deductible deductible

Prescription Drugs††

Retail and Mail Order (MOD) $10/$35/$50 $10/$35/$50 $10/$35/$50 $10/$35/$50 $10/$35/$50 (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/MOD supply)

Specialty Care Drugs 50% up to a 50% up to a 50% up to a 50% up to a 50% up to a maximum of $200 maximum of $200 maximum of $200 maximum of $200 maximum of $200 per scrip for up to a per scrip for up to a per scrip for up to a per scrip for up to a per scrip for up to a 30-day supply and 30-day supply and 30-day supply and 30-day supply and 30-day supply and up to a maximum of up to a maximum of up to a maximum of up to a maximum of up to a maximum of $400 per scrip for $400 per scrip for $400 per scrip for $400 per scrip for $400 per scrip for up to a 31- to up to a 31- to up to a 31- to up to a 31- to up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 12 Aetna 51-100 Health Network Only (HNOnly) Plan Option*

ME HNOnly 500 Plan Options 51-100 HD 20/30 51+

Member Benefits In-network

Member Coinsurance N/A

Calendar Year Deductible** $500 Individual (Embedded) $1,000 Family

Calendar Year Out-of-Pocket Maximum** $2,500 Individual (Embedded) $5,000 Family

Lifetime Maximum Benefit Unlimited

Primary Care Physician Office Visit $20 copay; deductible waived

Specialist Office Visit $30 copay; deductible waived

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, $0 copay; Routine Gyn Exams, Routine Mammograms, Routine deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months

Aetna VisionSM Discount Program Included

Outpatient Services $30 copay; (Lab and X-ray) deductible waived

Outpatient Complex Imaging 20%; (MRA/MRS, MRI, PET and CAT scans) deductible waived

Inpatient Hospital 20% after deductible

Outpatient Surgery 20% after deductible

Emergency Room $125 copay; (Copay waived if admitted) deductible waived

Urgent Care $125 copay; deductible waived

Outpatient Rehabilitation Therapy $30 copay; (50 combined visits per calendar year for physical, deductible waived occupational and speech therapy)

Chiropractic Services $30 copay; (36 visits per calendar year) deductible waived

Durable Medical Equipment 20%; ($2,500 calendar year maximum) deductible waived

Prescription Drugs††

Retail and Mail Order (MOD) $10/$35/$50 (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/MOD supply)

Specialty Care Drugs 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to 90-day supply

See pages 22–23 for footnotes. 13 Aetna 2-100 Open Choice® PPO HSA Compatible† Plan Options*

Plan Options 2-100 ME PPO 2500/80 HSA Compatible† ME PPO 3500/80 HSA Compatible†

Member Benefits Network Out-of-network◊ Network Out-of-network◊

Member Coinsurance 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Calendar Year Deductible** $2,500 Individual $5,000 Individual $3,500 Individual $7,000 Individual (Embedded) $5,000 Family $10,000 Family $7,000 Family $14,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $5,000 Individual $10,000 Individual $5,500 Individual $11,000 Individual (Embedded) $10,000 Family $20,000 Family $11,000 Family $22,000 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Non-Specialist Office Visit 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Specialist Office Visit 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; 40% after deductible 0%; 40% after deductible Routine Gyn Exams, Routine Mammograms, Routine deductible waived deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included Included

Outpatient Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible (Lab and X-ray)

Outpatient Complex Imaging 20% after deductible 40% after deductible 20% after deductible 40% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Outpatient Surgery 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Emergency Room 20% after deductible Paid as network 20% after deductible Paid as network

Urgent Care 20% after deductible Paid as network 20% after deductible Paid as network

Outpatient Rehabilitation Therapy 20% after deductible 40% after deductible 20% after deductible 40% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 20% after deductible 40% after deductible 20% after deductible 40% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) After integrated After integrated After integrated After integrated (1x copay up to a 30-day retail supply medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy 2x copay up to 31- to 90-day retail/MOD supply) deductible is met, deductible is met, 20% of deductible is met, deductible is met, 20% of $10/$35/$50 submitted cost after $10/$35/$50 submitted cost after $10/$35/ $50 $10/$35/ $50

Specialty Care Drugs After integrated After integrated After integrated After integrated medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy deductible is met, deductible is met, deductible is met, deductible is met, 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 14 Aetna 2-100 Open Choice® PPO HSA Compatible† Plan Options*

Plan Options 2-100 ME PPO 4500/80 HSA Compatible†

Member Benefits Network Out-of-network◊

Member Coinsurance 20% after deductible 40% after deductible

Calendar Year Deductible** $4,500 Individual $9,000 Individual (Embedded) $9,000 Family $18,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $6,050 Individual $18,000 Individual (Embedded) $12,100 Family $36,000 Family

Lifetime Maximum Benefit Unlimited Unlimited

Non-Specialist Office Visit 20% after deductible 40% after deductible

Specialist Office Visit 20% after deductible 40% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; 40% after deductible Routine Gyn Exams, Routine Mammograms, Routine deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included

Outpatient Services 20% after deductible 40% after deductible (Lab and X-ray)

Outpatient Complex Imaging 20% after deductible 40% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible 40% after deductible

Outpatient Surgery 20% after deductible 40% after deductible

Emergency Room 20% after deductible Paid as network

Urgent Care 20% after deductible Paid as network

Outpatient Rehabilitation Therapy 20% after deductible 40% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 20% after deductible 40% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 20% after deductible 40% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) After integrated After integrated (1x copay up to a 30-day retail supply medical/pharmacy medical/pharmacy 2x copay up to 31- to 90-day retail/MOD supply) deductible is met, deductible is met, 20% of $10/$35/$50 submitted cost after $10/$35/ $50

Specialty Care Drugs After integrated After integrated medical/pharmacy medical/pharmacy deductible is met, 50% deductible is met, 50% up to a maximum of up to a maximum of $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply

See pages 22–23 for footnotes. 15 Aetna 51-100 Open Choice® PPO HSA Compatible† Plan Options*

Plan Options 51-100 ME PPO 2500/80 HSA Compatible† 51+ ME PPO 3000/100 HSA Compatible† 51+

Member Benefits Network Out-of-network◊ Network Out-of-network◊

Member Coinsurance 20% after deductible 40% after deductible 0% after deductible 20% after deductible

Calendar Year Deductible** $2,500 Individual $5,000 Individual $3,000 Individual $4,500 Individual (Embedded) $5,000 Family $10,000 Family $6,000 Family $9,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $5,000 Individual $10,000 Individual $3,500 Individual $7,000 Individual (Embedded) $10,000 Family $20,000 Family $7,000 Family $14,000 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Non-Specialist Office Visit 20% after deductible 40% after deductible 0% after deductible 20% after deductible

Specialist Office Visit 20% after deductible 40% after deductible 0% after deductible 20% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; deductible waived 40% after deductible 0%; deductible waived 20% after deductible Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included Included

Outpatient Services 20% after deductible 40% after deductible 0% after deductible 20% after deductible (Lab and X-ray)

Outpatient Complex Imaging 20% after deductible 40% after deductible 0% after deductible 20% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible 40% after deductible 0% after deductible 20% after deductible

Outpatient Surgery 20% after deductible 40% after deductible 0% after deductible 20% after deductible

Emergency Room 20% after deductible Paid as network 0% after deductible Paid as network

Urgent Care 20% after deductible Paid as network 0% after deductible Paid as network

Outpatient Rehabilitation Therapy 20% after deductible 40% after deductible 0% after deductible 20% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 20% after deductible 40% after deductible 0% after deductible 20% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 20% after deductible 40% after deductible 0% after deductible 20% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) After Integrated After Integrated After Integrated After Integrated (1x copay up to a 30-day retail supply medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy 2x copay up to 31- to 90-day retail/MOD supply) deductible⸋ is met, deductible⸋ is met, 20% deductible⸋ is met, deductible⸋ is met, 20% $10/$35/$50 of submitted cost after $10/$35/$50 of submitted cost after $10/$35/$50 $10/$35/$50

Specialty Care Drugs After Integrated After Integrated After Integrated After Integrated medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 16 Aetna 51-100 Open Choice® PPO HSA Compatible† Plan Options*

Plan Options 51-100 ME PPO 3500/80 HSA Compatible† 51+ ME PPO 4500/80 HSA Compatible† 51+

Member Benefits Network Out-of-network◊ Network Out-of-network◊

Member Coinsurance 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Calendar Year Deductible** $3,500 Individual $7,000 Individual $4,500 Individual $9,000 Individual (Embedded) $7,000 Family $14,000 Family $9,000 Family $18,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $5,500 Individual $11,000 Individual $6,050 Individual $18,000 Individual (Embedded) $11,000 Family $22,000 Family $12,100 Family $36,000 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Non-Specialist Office Visit 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Specialist Office Visit 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; deductible waived 40% after deductible 0%; deductible waived 40% after deductible Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included Included

Outpatient Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible (Lab and X-ray)

Outpatient Complex Imaging 20% after deductible 40% after deductible 20% after deductible 40% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Outpatient Surgery 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Emergency Room 20% after deductible Paid as network 20% after deductible Paid as network

Urgent Care 20% after deductible Paid as network 20% after deductible Paid as network

Outpatient Rehabilitation Therapy 20% after deductible 40% after deductible 20% after deductible 40% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 20% after deductible 40% after deductible 20% after deductible 40% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) After Integrated After Integrated After Integrated After Integrated (1x copay up to a 30-day retail supply medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy 2x copay up to 31- to 90-day retail/MOD supply) deductible⸋ is met, deductible⸋ is met, 20% deductible⸋ is met, deductible⸋ is met, 20% $10/$35/$50 of submitted cost after $10/$35/$50 of submitted cost after $10/$35/$50 $10/$35/$50

Specialty Care Drugs After Integrated After Integrated After Integrated After Integrated medical/pharmacy medical/pharmacy medical/pharmacy medical/pharmacy deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, deductible⸋ is met, 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 17 Aetna 2-100 Open Choice® PPO Plan Options*

Plan Options 2-100 ME PPO 1500/80 ME PPO 2500/80

Member Benefits Network Out-of-network◊ Network Out-of-network◊

Member Coinsurance 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Calendar Year Deductible** $1,500 Individual $3,000 Individual $2,500 Individual $4,000 Individual (Embedded) $3,000 Family $6,000 Family $5,000 Family $8,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $4,000 Individual $6,000 Individual $5,000 Individual $6,500 Individual (Embedded) $8,000 Family $12,000 Family $10,000 Family $13,000 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Non-Specialist Office Visit $30 copay; 40% after deductible $30 copay; 40% after deductible deductible waived deductible waived

Specialist Office Visit $45 copay; 40% after deductible $45 copay; 40% after deductible deductible waived deductible waived

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, $0 copay; 40% after deductible $0 copay; 40% after deductible Routine Gyn Exams, Routine Mammograms, Routine deductible waived deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included Included

Outpatient Services $45 copay after 40% after deductible $45 copay after 40% after deductible (Lab and X-ray) deductible deductible

Outpatient Complex Imaging 20% after deductible 40% after deductible 20% after deductible 40% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Outpatient Surgery 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Emergency Room $150 copay; Paid as network $150 copay; Paid as network (Copay waived if admitted) deductible waived deductible waived

Urgent Care $150 copay; Paid as network $150 copay; Paid as network deductible waived deductible waived

Outpatient Rehabilitation Therapy 20% after deductible 40% after deductible 20% after deductible 40% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 20% after deductible 40% after deductible 20% after deductible 40% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) $10/$35/$50 20% of submitted cost $10/$35/$50 20% of submitted cost (1x copay up to a 30-day retail supply after $10/$35/$50 after $10/$35/$50 2x copay up to 31- to 90-day retail/MOD supply)

Specialty Care Drugs 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 18 Aetna 2-100 Open Choice® PPO Plan Options*

Plan Options 2-100 ME PPO 3500/80 ME PPO 5000/80

Member Benefits Network Out-of-network◊ Network Out-of-network◊

Member Coinsurance 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Calendar Year Deductible** $3,500 Individual $5,000 Individual $5,000 Individual $7,500 Individual (Embedded) $7,000 Family $10,000 Family $10,000 Family $15,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $6,000 Individual $7,500 Individual $7,000 Individual $10,000 Individual (Embedded) $12,000 Family $15,000 Family $14,000 Family $20,000 Family

Lifetime Maximum Benefit Unlimited Unlimited Unlimited Unlimited

Non-Specialist Office Visit $30 copay; 40% after deductible $30 copay; 40% after deductible deductible waived deductible waived

Specialist Office Visit $45 copay; 40% after deductible $50 copay; 40% after deductible deductible waived deductible waived

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, $0 copay; 40% after deductible $0 copay; 40% after deductible Routine Gyn Exams, Routine Mammograms, Routine deductible waived deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included Included

Outpatient Services $45 copay after 40% after deductible $50 copay after 40% after deductible (Lab and X-ray) deductible deductible

Outpatient Complex Imaging 20% after deductible 40% after deductible 20% after deductible 40% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Outpatient Surgery 20% after deductible 40% after deductible 20% after deductible 40% after deductible

Emergency Room $150 copay; Paid as network $150 copay; Paid as network (Copay waived if admitted) deductible waived deductible waived

Urgent Care $150 copay; Paid as network $150 copay; Paid as network deductible waived deductible waived

Outpatient Rehabilitation Therapy 20% after deductible 40% after deductible 20% after deductible 40% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 20% after deductible 40% after deductible 20% after deductible 40% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) $10/$35/$50 20% of submitted cost $10/$35/$50 20% of submitted cost (1x copay up to a 30-day retail supply after $10/$35/$50 after $10/$35/$50 2x copay up to 31- to 90-day retail/MOD supply)

Specialty Care Drugs 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply 90-day supply 90-day supply

See pages 22–23 for footnotes. 19 Aetna 51-100 Open Choice® PPO Plan Option*

Plan Option 51-100 ME PPO 1000/90 51+

Member Benefits Network Out-of-network◊

Member Coinsurance 10% after deductible 30% after deductible

Calendar Year Deductible** $1,000 Individual $2,000 Individual (Embedded) $2,000 Family $4,000 Family

Calendar Year Maximum Out-of-Pocket Limit** $2,500 Individual $5,000 Individual (Embedded) $5,000 Family $10,000 Family

Lifetime Maximum Benefit Unlimited Unlimited

Non-Specialist Office Visit $20 copay; 30% after deductible deductible waived

Specialist Office Visit $30 copay; 30% after deductible deductible waived

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, $0 copay; 30% after deductible Routine Gyn Exams, Routine Mammograms, Routine deductible waived DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months (Network and out-of-network combined)

Aetna VisionSM Discount Program Included

Outpatient Services $30 copay after 30% after deductible (Lab and X-ray) deductible

Outpatient Complex Imaging 10% after deductible 30% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 10% after deductible 30% after deductible

Outpatient Surgery 10% after deductible 30% after deductible

Emergency Room $100 copay; Paid as network (Copay waived if admitted) deductible waived

Urgent Care $100 copay; Paid as network deductible waived

Outpatient Rehabilitation Therapy 10% after deductible 30% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy; network and out-of-network combined)

Chiropractic Services 10% after deductible 30% after deductible (36 visits per calendar year; network and out-of-network combined)

Durable Medical Equipment 10% after deductible 30% after deductible ($2,500 calendar year maximum; network and out-of-network combined)

Prescription Drugs††

Retail and Mail Order (MOD) $10/$35/$50 20% of submitted cost (1x copay up to a 30-day retail supply after $10/$35/$50 2x copay up to 31- to 90-day retail/MOD supply)

Specialty Care Drugs 50% up to a maximum of 50% up to a maximum of $200 per scrip for up to a $200 per scrip for up to a 30-day supply and up to 30-day supply and up to a maximum of $400 per a maximum of $400 per scrip for up to a 31- to scrip for up to a 31- to 90-day supply 90-day supply

See pages 22–23 for footnotes. 20 Aetna 2-100 Traditional Choice® Plan Option*

ME Traditional Plan Option 2-100 Choice 2500/80

Member Benefits

Member Coinsurance 20% after deductible

Calendar Year Deductible** $2,500 Individual (Embedded) $5,000 Family

Calendar Year Out-of-Pocket Maximum** $4,500 Individual (Embedded) $9,000 Family

Lifetime Maximum Benefit Unlimited

Non-Specialist Office Visit 20% after deductible

Specialist Office Visit 20% after deductible

Preventive Care

Well-Child Exams, Immunizations, Adult Physicals, 0%; deductible waived Routine Gyn Exams, Routine Mammograms, Routine DRE, Routine PSA, Routine Colorectal Cancer Screening & Routine Vision Exams (Age and frequency schedules apply)

Vision Eyewear $100 every 24 months

Aetna VisionSM Discount Program Included

Outpatient Services 20% after deductible (Lab and X-ray)

Outpatient Complex Imaging 20% after deductible (MRA/MRS, MRI, PET and CAT scans)

Inpatient Hospital 20% after deductible

Outpatient Surgery 20% after deductible

Emergency Room 20% after deductible

Urgent Care 20% after deductible

Outpatient Rehabilitation Therapy 20% after deductible (50 combined visits per calendar year for physical, occupational and speech therapy)

Chiropractic Services 20% after deductible (36 visits per calendar year)

Durable Medical Equipment 20% after deductible ($2,500 Calendar Year Maximum)

Prescription Drugs††

Retail and Mail Order (MOD) $10/$35/$50 (1x copay up to a 30-day retail supply 2x copay up to 31- to 90-day retail/MOD supply)

Specialty Care Drugs 50% up to a maximum of $200 per scrip for up to a 30-day supply and up to a maximum of $400 per scrip for up to a 31- to 90-day supply

See pages 22–23 for footnotes. 21 Medical Plans for 2–100 Eligible Enrolling Footnotes

*This is a partial description of benefits available. For more PPO: All covered expenses accumulate separately toward the information, refer to the specific plan design summary. network and out-of-network deductible and maximum Dollar amount copayments and percentage coinsurance out-of-pocket limit. Only those out-of-pocket expenses amounts indicate what the member is required to pay. resulting from the application of deductible and coinsurance percentage may be used to satisfy the maximum **HNOnly HSA Compatible plans: Only those out-of-pocket out-of-pocket limit; and certain services may not apply expenses resulting from the application of deductible, toward the deductible or maximum out-of-pocket limit. coinsurance percentage and copays, including prescription Once the family deductible/maximum out-of-pocket limit is drug copays, may be used to satisfy the out-of-pocket met, all family members will be considered as having met their maximum. Once the family deductible/maximum deductible/maximum out-of-pocket limit for the remainder of out-of-pocket limit is met, all family members will be the calendar year. No one family member may contribute more considered as having met their deductible/maximum than the individual deductible/maximum out-of-pocket limit out-of-pocket limit for the remainder of the calendar year. to the family deductible/maximum out-of-pocket limit. No one family member may contribute more than the Deductible carryover is not included. individual deductible/maximum out-of-pocket limit to the family deductible/maximum out-of-pocket limit. Traditional Choice plan: All covered expenses accumulate Deductible carryover is not included. toward the deductible and maximum out-of-pocket limit. Only those out-of-pocket expenses resulting from the PPO HSA Compatible plans: All covered expenses, including application of deductible and coinsurance percentage may prescription drugs, accumulate separately toward the network be used to satisfy the maximum out-of-pocket limit; and and out-of-network deductible and maximum out-of-pocket certain services may not apply toward the deductible or limit; only those out-of-pocket expenses resulting from the maximum out-of-pocket limit. Once the family deductible/ application of deductible, coinsurance percentage and copays, maximum out-of-pocket limit is met, all family members will including prescription drug copays, may be used to satisfy the be considered as having met their deductible/maximum maximum out-of-pocket limit; and certain services may not out-of-pocket limit for the remainder of the calendar year. apply toward the deductible or maximum out-of-pocket limit. No one family member may contribute more than the Once the family deductible/maximum out-of-pocket limit is individual deductible/maximum out-of-pocket limit to the met, all family members will be considered as having met their family deductible/maximum out-of-pocket limit. deductible/maximum out-of-pocket limit for the remainder of Deductible carryover is not included. the calendar year. No one family member may contribute more than the individual deductible/maximum out-of-pocket limit to the family deductible/maximum out-of-pocket limit. Deductible carryover is not included. HNOnly plans: Only those out-of-pocket expenses resulting from the application of deductible and coinsurance percentage may be used to satisfy the out-of-pocket maximum; and certain services may not apply toward the deductible or out-of-pocket maximum. Once the family deductible/out-of-pocket maximum is met, all family members will be considered as having met their deductible/ out-of-pocket maximum for the remainder of the calendar year. No one family member may contribute more than the individual deductible/out-of-pocket maximum amount to the family deductible/out-of-pocket maximum. Deductible carryover is not included.

22 †Based upon United States Treasury guidance available as of No dollar amount above the “recognized charge” counts the print date. toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit ††Pharmacy plans include prior authorization and step-therapy. www.aetna.com. Type “how Aetna pays” in the search box. 90-Day transition of coverage (TOC) for prior authorization and step-therapy included on pharmacy plans. Transition of You can avoid these extra costs by getting your care coverage for prior authorization and step-therapy helps from Aetna’s broad network of health care providers. Go to members of new groups to transition to Aetna by providing a www.aetna.com and click on “Find a Doctor” on the left side 90-calendar-day opportunity, beginning on the group’s initial of the page. If you are already a member, sign on to your effective date, during which time prior authorization and Aetna Navigator member site. step-therapy requirements will not apply to certain drugs. This applies when you choose to get care out of network. Once the 90 calendar days has expired, prior authorization When you have no choice (for example: emergency room visit and step-therapy edits will apply to all drugs requiring prior after a car accident, or for other emergency services), we will authorization and step-therapy as listed in the formulary pay the bill as if you got care in network. You pay cost sharing guide. Members who have claims paid for a drug requiring prior and deductibles for your in-network level of benefits. authorization and step-therapy during the transition Contact Aetna if your provider asks you to pay more. You are of coverage period may continue to receive this drug after not responsible for any outstanding balance billed by your the 90 calendar days and will not be required to obtain a prior providers for emergency services beyond your cost sharing authorization or approval for a medical exception for this and deductibles. drug. NOTE: step-therapy and TOC for step-therapy are not included on HSA Compatible plans. Women’s Preventive Health Benefits: The following Women’s Preventive Health Benefits generally are covered at no cost The integrated medical/pharmacy deductible is waived for ⸋ share, when provided in network: certain preventive medications. Please refer to www.aetna.com for the Preventive Medications listing. • Well-woman visits (annually and now including prenatal visits) • Screening for gestational diabetes Some benefits are subject to limitations or visit maximums. Members or providers may be required to precertify or obtain • Human papillomavirus (HPV) DNA testing prior approval for certain services such as non-emergency • Counseling for sexually transmitted infections hospital care. • Counseling and screening for human immunodeficiency ◊We cover the cost of services based on whether doctors are virus (HIV) “in network” or “out of network.” We want to help you • Screening and counseling for interpersonal and domestic understand how much Aetna pays for your out-of-network violence care. At the same time, we want to make it clear how much • Breastfeeding support, supplies and counseling more you will need to pay for this “out-of-network” care. • Generic formulary contraceptives are covered without member You may choose a provider (doctor or hospital) in our network. cost-share (for example, no copayment). Certain religious You may choose to visit an out-of-network provider. If you organizations or religious employers may be exempt from choose a doctor who is out of network, your Aetna health plan offering contraceptive services. may pay some of that doctor’s bill. Most of the time, you will Note: For a summary list of Limitations and Exclusions, refer to pay a lot more money out of your own pocket if you choose to pages 58–59. use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the “recognized” or “allowed” amount. When you choose out-of-network care, Aetna “recognizes” an amount based on what Medicare pays for these services. The government sets the Medicare rate. Your doctor sets his or her own rate to charge you. It may be higher – sometimes much higher – than what your Aetna plan “recognizes.” Your doctor may bill you for the dollar amount that Aetna doesn’t “recognize.” You must also pay any copayments, coinsurance and deductibles under your plan.

23 Aetna Dental Plans Small-business decision makers can choose from a variety of plan design options that help you offer a dental benefits and dental insurance plan that’s just right for your employees.

24 Dental Overview

The Mouth MattersSM Voluntary Dental option Research suggests that serious gum disease, known as The Voluntary Dental option provides a solution to meet the periodontitis, may be associated with many health problems. individual needs of members in the face of rising health care This is especially true if gum disease continues without costs. Administration is easy, and members benefit from low treatment.1,2 Now, here’s the good news. Researchers are group rates and the convenience of payroll deductions. discovering that a healthy mouth may be important to your overall health.1,2 Aetna Dental® Indemnity plan The Aetna Dental/Medical IntegrationSM program,* available at no Aetna offers a variety of traditional fee-for-service or additional charge to plan sponsors that have both medical and indemnity dental plan designs. Members have the freedom dental coverage with Aetna, focuses on those who are pregnant to visit any licensed dentist for covered services and no or have diabetes, coronary artery disease (heart disease) or referrals are required. Members are required to meet an annual cerebrovascular disease (stroke) and have not had a recent dental deductible before the plan will begin to pay for covered visit. We proactively educate those at-risk members about the services, and coverage may be subject to annual and lifetime impact oral health care can have on their condition. Our member benefit maximums. Most preventive and diagnostic services, outreach has been proven to successfully motivate those at-risk like oral exams, cleanings and X-rays, are not subject to the members who do not normally seek dental care to visit the annual deductible. dentist. Once at the dentist, these at-risk members will receive enhanced dental benefits including an extra cleaning and full Scheduled Indemnity plan coverage for certain periodontal services. Members can choose any licensed dentist for services and Preferred Provider Organization (PPO) plan pay deductibles and coinsurance up to an annual maximum. Members can be balance billed and may be required to Members can choose a dentist who participates in the network file claims. or choose a licensed dentist who does not. Participating dentists have agreed to offer our members covered services at a negotiated rate and will not balance-bill members.

1MayoClinic.com. “Oral health: A window to your overall health.” Available online at www.mayoclinic.com/health/dental/DE00001. Accessed May 2010. 2R.C. Williams, A.H. Barnett, N. Claffey, M. Davis, R. Gadsby, M. Kellett, G.Y.H. Lip, and S. Thackray. “The potential impact of periodontal disease on general health: a consensus view.” Current Medical Research and Opinion, Vol. 24, No. 6, 2008, 1635-1643. *DMI may not be available in all states. 25 Dental Plans 2–9

Option 1 Option 2 Option 3

per schedule 80/60/40 100/80/50 Annual Deductible per Member $75; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum (does not apply to diagnostic & preventive services) Annual Maximum Benefit $1,000 $1,000 $1,000 Diagnostic Services Oral Exams Periodic oral exam $14 80% 100% Comprehensive oral exam $23 80% 100% Problem-focused oral exam $46 80% 100% X-rays Bitewing — single film $7 80% 100% Complete series $44 80% 100% Preventive Services Adult cleaning $31 80% 100% Child cleaning $23 80% 100% Sealants — per tooth $19 80% 100% Fluoride application — with cleaning $29 80% 100% Space maintainers $64 80% 100% Basic Services Amalgam filling — 2 surfaces $31 60% 80% Resin filling — 2 surfaces, anterior $35 60% 80% Oral Surgery Extraction — exposed root or erupted tooth $20 60% 80% Extraction of impacted tooth — soft tissue $54 60% 80% Major Services* Complete upper denture $234 40% 50% Partial upper denture $192 40% 50% Crown — Porcelain with noble metal $192 40% 50% Pontic — Porcelain with noble metal $181 40% 50% Inlay — Metallic (3 or more surfaces) $189 40% 50% Oral Surgery Removal of impacted tooth — partially bony $70 40% 50% Endodontic Services Bicuspid root canal therapy $149 40% 50% Molar root canal therapy $178 40% 50% Periodontic Services Scaling & root planing — per quadrant $42 40% 50% Osseous surgery — per quadrant $195 40% 50% Orthodontic Services Not covered Not covered Not covered Orthodontic lifetime maximum Does not apply Does not apply Does not apply

See page 29 for footnotes. 26 Dental Plans 2–9

Option 4 Option 5

100/80/50 100/80/50 Annual Deductible per Member $50; 3X Family maximum $50; 3X Family maximum (does not apply to diagnostic & preventive services) Annual Maximum Benefit $1,500 $1,500 Diagnostic Services Oral Exams Periodic oral exam 100% 100% Comprehensive oral exam 100% 100% Problem-focused oral exam 100% 100% X-rays Bitewing — single film 100% 100% Complete series 100% 100% Preventive Services Adult cleaning 100% 100% Child cleaning 100% 100% Sealants — per tooth 100% 100% Fluoride application — with cleaning 100% 100% Space maintainers 100% 100% Basic Services Amalgam filling — 2 surfaces 80% 80% Resin filling — 2 surfaces, anterior 80% 80% Oral Surgery Extraction — exposed root or erupted tooth 80% 80% Extraction of impacted tooth — soft tissue 80% 80% Major Services* Complete upper denture 50% 50% Partial upper denture 50% 50% Crown — Porcelain with noble metal 50% 50% Pontic — Porcelain with noble metal 50% 50% Inlay — Metallic (3 or more surfaces) 50% 50% Oral Surgery Removal of impacted tooth — partially bony 50% 50% Endodontic Services Bicuspid root canal therapy 50% 80% Molar root canal therapy 50% 50% Periodontic Services Scaling & root planing — per quadrant 50% 80% Osseous surgery — per quadrant 50% 50% Orthodontic Services Not covered Not covered Orthodontic lifetime maximum Does not apply Does not apply

See page 29 for footnotes. 27 Voluntary Dental Plans 3–9

Voluntary Option 1 Voluntary Option 2 Voluntary Option 3

80/60/40 100/80/50 100/80/50 Annual Deductible per Member $50; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum (does not apply to diagnostic & preventive services) Annual Maximum Benefit $1,000 $1,500 $1,500 Diagnostic Services Oral Exams Periodic oral exam 80% 100% 100% Comprehensive oral exam 80% 100% 100% Problem-focused oral exam 80% 100% 100% X-rays Bitewing — single film 80% 100% 100% Complete series 80% 100% 100% Preventive Services Adult cleaning 80% 100% 100% Child cleaning 80% 100% 100% Sealants — per tooth 80% 100% 100% Fluoride application — with cleaning 80% 100% 100% Space maintainers 80% 100% 100% Basic Services Amalgam filling — 2 surfaces 60% 80% 80% Resin filling — 2 surfaces, anterior 60% 80% 80% Oral Surgery Extraction — exposed root or erupted tooth 60% 80% 80% Extraction of impacted tooth — soft tissue 60% 80% 80% Major Services* Complete upper denture 40% 50% 50% Partial upper denture 40% 50% 50% Crown — Porcelain with noble metal 40% 50% 50% Pontic — Porcelain with noble metal 40% 50% 50% Inlay — Metallic (3 or more surfaces) 40% 50% 50% Oral Surgery Removal of impacted tooth — partially bony 40% 50% 50% Endodontic Services Bicuspid root canal therapy 40% 50% 80% Molar root canal therapy 40% 50% 50% Periodontic Services Scaling & root planing — per quadrant 40% 50% 80% Osseous surgery — per quadrant 40% 50% 50% Orthodontic Services Not covered Not covered Not covered Orthodontic lifetime maximum Does not apply Does not apply Does not apply

See page 29 for footnotes. 28 Dental Plans Footnotes

Dental Plans for 2-9 *Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any major service. Most oral surgery, endodontic and periodontic procedures are covered as basic services in Plan Option 5 and are not subject to the coverage waiting period. All dollar amounts and percentages indicate what the plan will pay. Actual plan payments on Plan Options 2-5 are limited by geographic area prevailing fees at the 80th percentile for Plan Options 2-4 and the 90th percentile on Plan Option 5. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change.

Voluntary Dental Plans for 3-9 *Coverage Waiting Period: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any major service. Most oral surgery, endodontic and periodontic services are covered as basic services in Voluntary Option 3. Actual plan payments on Voluntary Plan Options 1-3 are limited by geographic area prevailing fees at the 80th percentile for Voluntary Plan Options 1 & 2 and the 90th percentile on Voluntary Plan Option 3. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the coverage waiting period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 59.

29 Dental Plans 10-100

Option 1A Option 2A Option 3A Indemnity 1000 95th Indemnity 1500 95th Indemnity 2000 95th

Indemnity 1000 95th Indemnity 1500 95th Indemnity 2000 95th 100/80/50 100/80/50 100/80/50 Annual Deductible per Member $50; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum (does not apply to diagnostic & preventive services) Annual Maximum Benefit $1,000 $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% Comprehensive oral exam 100% 100% 100% Problem-focused oral exam 100% 100% 100% X-rays Bitewing - single film 100% 100% 100% Complete series 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% Child cleaning 100% 100% 100% Sealants - per tooth 100% 100% 100% Fluoride application - with cleaning 100% 100% 100% Space maintainers 100% 100% 100% Basic Services Amalgam filling - 2 surfaces 80% 80% 80% Resin filling - 2 surfaces, anterior 80% 80% 80% Endodontic Services Bicuspid root canal therapy 80% 80% 80% Molar root canal therapy 80% 80% 80% Periodontic Services Scaling & root planing - per quadrant 80% 80% 80% Osseous surgery - per quadrant 80% 80% 80% Oral Surgery Extraction - exposed root or erupted tooth 80% 80% 80% Extraction of impacted tooth - soft tissue 80% 80% 80% Removal of impacted tooth - partially bony 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% Partial upper denture 50% 50% 50% Crown - Porcelain with noble metal 50% 50% 50% Pontic - Porcelain with noble metal 50% 50% 50% Inlay - Metallic (3 or more surfaces) 50% 50% 50% Orthodontic Services (optional)* 50% 50% 50% Orthodontic lifetime maximum $1,000 $1,000 $1,000

See page 32 for footnotes. 30 Dental Plans 10-100

Option 4A Option 5A Option 6A Option 7A PPO 1000 PPO 1250 PPO 1500 PPO 2000

PPO 1000 Plan PPO 1250 Plan PPO 1500 Plan PPO 2000 Plan 100/80/50 100/80/50 100/80/50 100/80/50 Annual Deductible per Member $50; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum $50; 3X Family maximum (does not apply to diagnostic & preventive services) Annual Maximum Benefit $1,000 $1,250 $1,500 $2,000 Diagnostic Services Oral Exams Periodic oral exam 100% 100% 100% 100% Comprehensive oral exam 100% 100% 100% 100% Problem-focused oral exam 100% 100% 100% 100% X-rays Bitewing - single film 100% 100% 100% 100% Complete series 100% 100% 100% 100% Preventive Services Adult cleaning 100% 100% 100% 100% Child cleaning 100% 100% 100% 100% Sealants - per tooth 100% 100% 100% 100% Fluoride application - with cleaning 100% 100% 100% 100% Space maintainers 100% 100% 100% 100% Basic Services Amalgam filling - 2 surfaces 80% 80% 80% 80% Resin filling - 2 surfaces, anterior 80% 80% 80% 80% Endodontic Services Bicuspid root canal therapy 80% 80% 80% 80% Molar root canal therapy 80% 80% 80% 80% Periodontic Services Scaling & root planing - per quadrant 80% 80% 80% 80% Osseous surgery - per quadrant 80% 80% 80% 80% Oral Surgery Extraction - exposed root or erupted tooth 80% 80% 80% 80% Extraction of impacted tooth - soft tissue 80% 80% 80% 80% Removal of impacted tooth - partially bony 80% 80% 80% 80% Major Services* Complete upper denture 50% 50% 50% 50% Partial upper denture 50% 50% 50% 50% Crown - Porcelain with noble metal 50% 50% 50% 50% Pontic - Porcelain with noble metal 50% 50% 50% 50% Inlay - Metallic (3 or more surfaces) 50% 50% 50% 50% Orthodontic Services (optional)* 50% 50% 50% 50% Orthodontic lifetime maximum $1,000 $1,000 $1,000 $1,000

See page 32 for footnotes. 31 Dental Plans for 10–100 Footnotes

*Coverage Waiting Period applies to Voluntary Dental Plans: Must be an enrolled member of the plan for 12 months before becoming eligible for coverage of any major service including orthodontic services. All oral surgery, endodontic and periodontic procedures are covered as basic services. All dollar amounts and percentages indicate what the plan will pay. Actual plan payments on Plan Options 1A-3A are limited by geographic area prevailing fees at the 95th percentile. On Plan Options 4A & 7A, out-of-network plan payments are limited by geographic area to the prevailing fees at the 95th percentile. Orthodontic coverage is available in Plan Options 1A-7A to dependent children only. Plan features and availability may vary by location and are subject to change. Information is believed to be accurate as of the production date; however, it is subject to change. Voluntary Plans: If there is a lapse in coverage, members may not re-enroll in the plan for a period of two years from the date of termination. If they are eligible for coverage at that time, they may re-enroll, subject to all provisions of the plan, including, but not limited to, the coverage waiting period. Above list of covered services is representative. Full list with limitations as determined by Aetna appears in the plan booklet/ certificate. For a summary list of Limitations and Exclusions, refer to page 59.

32 Aetna Life & Disability Group life and disability is an affordable way to provide life insurance and disability benefits to employees that will help them establish financial protection for themselves and their families.

33 Life & Disability Overview

For groups of 2 to 50, Aetna Life Insurance Company (Aetna) Life insurance Small Group packaged life and disability insurance plans include We know that life insurance is an important part of the benefits a range of flat-dollar insurance options bundled together in one package you offer your employees. That’s why our products and monthly per-employee rate. These products are easy to programs are designed to meet your needs for: understand and offer affordable benefits to help your employees protect their families in the event of illness, injury or death. You’ll • Flexibility benefit from streamlined plan installation, administration and • Added value claims processing, and all of the benefits of our stand-alone life • Cost-efficiency and disability products for small groups. Or, simply choose from • Experienced support our portfolio of group basic term life and disability insurance plans. We help you give employees what they’re looking for in lifestyle protection, through our selected group life insurance options. For groups of 51 and above, Aetna offers a robust portfolio of And we look beyond the benefits payout to include useful life and disability products with flexible plan features. Please enhancements through the Aetna Life EssentialsSM program. consult your sales representative for a plan designed to meet your group’s needs: So what’s the bottom line? A portfolio of value-packed products and programs to attract and retain workers — while making the • Basic life most of the benefits dollars you spend. • Supplemental life • AD&D Ultra® Giving you (and your employees) what you want • Supplemental AD&D Ultra® Employees are looking for cost-efficient plan features and • Dependent life value-added programs that help them make better decisions for themselves and their dependents. • Short-term disability • Long-term disability Our life insurance plans come with a variety of features including: Accelerated death benefit — Also called the “living benefit,” the accelerated death benefit provides payment to terminally ill employees or spouses. This payment can be up to 75 percent of the life insurance benefit. Premium waiver provision — Employee coverage may stay in effect up to age 65 without premium payments if an employee becomes permanently and totally disabled while insured due to an illness or injury prior to age 60. Optional dependent life — This feature allows employees to add optional additional coverage for eligible spouses and children for employers with 10 or more employees. This employee-paid benefit enables employees to cover their spouses and dependent children.

Our fresh approach to life With Aetna Life EssentialsSM, your employees have access to programs during their active lives to help promote healthy, fulfilling lifestyles. In addition, Aetna Life EssentialsSM provides for critical caring and support resources for often-overlooked needs during the end of one’s life. And we also include value for beneficiaries and their loved ones well beyond the financial support from a death benefit.

34 AD&D Ultra® Integrated Health and Disability AD&D Ultra is standardly included with our small group term life With our Integrated Health and Disability program, we can link plans and in our packaged life and disability plans, and provides medical and disability data to help anticipate concerns, take action employees and their families with the same coverage as a typical and get your employees back to work sooner. accidental death and dismemberment plan — and then some. • Predictive modeling identifies medical members most likely to This includes extra benefits at no additional cost to you, such as experience a disability, potentially preventing a disability from coverage for education or child-care expenses that make this occurring or minimizing the impact for better outcomes. protection even more valuable. • Health Insurance Portability and Accountability Act Covered losses include: (HIPAA)-compliant so medical and disability staff can share • Death clinical information and work jointly with the employee to help address medical and disability issues. • Dismemberment • Referrals between health case managers and their disability • Loss of sight counterparts help ensure better consistency and integration. • Loss of speech • The Integrated Health and Disability program is available at no • Loss of hearing additional cost when a member has both medical and disability • Third-degree burns coverage from Aetna. • Paralysis For a summary list of Limitations and Exclusions, • Coma refer to pages 59–60. • Total disability • Exposure and disappearance Extra benefits for the following: • Passenger restraint use and airbag deployment* • Education assistance for dependent child and/or spouse* • Child care* • Repatriation of mortal remains*

Disability insurance Finding disability insurance or benefits for you and your employees isn’t difficult. Many companies offer them. The challenge is finding the right plan … one that will meet the distinct needs of your business. Aetna understands this. Our in-depth approach to disability helps give us a clear understanding of what you and your employees need … and then helps meet those needs. You’ll get the right resources, the right support and the right care for your employees at the right time. • Our clinically based disability model ensures claims and duration guidelines are fact-based with objective benchmarks. • We offer a holistic approach that takes the whole person into account. • We give you 24-hour access to claim information. • We provide return-to-work programs to help ensure employees are back to work as soon as it’s medically safe to do so. • We employ vocational rehabilitation and ergonomic specialists who can help restore employees back to health and productive employment.

Life insurance policies and disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). *Only available if insured loses life. 35 Term Life Plan Options

2-9 Employees 10-50 Employees

Basic Life Schedule Flat $10,000, $15,000, $20,000, $50,000 Flat $10,000, $15,000, $20,000, $50,000, $75,000, $100,000, $125,000 Class Schedules Not available Up to 3 classes (with a minimum requirement of 3 employees in each class) — the benefit amount of the highest class cannot be more than 5 times the benefit amount of the lowest class Premium Waiver Provision Premium Waiver 60 Premium Waiver 60 Age Reduction Schedule Original life amount reduces to 65% at age 65; Original life amount reduces to 65% at age 65; 40% at age 70; 25% at age 75 40% at age 70; 25% at age 75 Accelerated Death Benefit Up to 75% of life amount for terminal illness Up to 75% of life amount for terminal illness Guaranteed Issue $20,000 10-25 employees $75,000 26-50 employees $100,000 Participation Requirements 100% 100% on noncontributory plans; 75% on contributory plans Contribution Requirements 100% employer contribution Minimum 50% employer contribution AD&D Ultra® AD&D Ultra Schedule Matches life benefit Matches life benefit AD&D Ultra Extra Benefits Passenger restraint use and airbag deployment, education Passenger restraint use and airbag deployment, education benefit for your child and/or spouse, child care and benefit for your child and/or spouse, child care and repatriation of mortal remains. repatriation of mortal remains. Optional Dependent Term Life Spouse Amount Not available $5,000 Child Amount Not available $2,000

For plan options for group size 51 and above, please consult your Aetna account executive. Disability Plan Options

Plan Options 2-50 Short Term Benefits Plan Option 1 Plan Option 2

Plan Amount Choice of flat $100 increments to a maximum of $500 weekly Choice of flat $100 increments to a maximum of $500 weekly Benefits Start — Accident 1 day 8 days Benefits Start — Illness 8 days 8 days Maximum Benefit Period 26 weeks 26 weeks Maternity Benefit Maternity treated same as any other disability but is Maternity treated same as any other disability but is subject to pre-existing. If pregnant before the effective subject to pre-existing. If pregnant before the effective date, the pregnancy is not covered unless she has prior date, the pregnancy is not covered unless she has prior creditable coverage. creditable coverage. Pre-Existing Conditions Rule 3/12 3/12 Actively-at-Work Rule Applies Applies Other Income Offset Integration N/A N/A Other Income Offset Integration Earnings loss of 20% or more Earnings loss of 20% or more Definition of Disability Earnings loss of 20% or more Earnings loss of 20% or more Class Schedules Up to 3 classes (with a minimum requirement of Up to 3 classes (with a minimum requirement of 3 employees in each class) available for groups of 3 employees in each class) available for groups of 10 or more employees 10 or more employees

For plan options for group size 51 and above, please consult your Aetna account executive.

Life insurance policies and disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). 36 Packaged Life and Disability Plan Options

Plan Options 2-50 Basic Life Plan Design Low Option Medium Option High Option

Benefit Flat $10,000 Flat $20,000 Flat $50,000

Guaranteed Issue 2-9 Lives $10,000 $20,000 $20,000 10-50 Lives $10,000 $20,000 $50,000

Reduction Schedule Employee’s original life amount Employee’s original life amount Employee’s original life amount reduces to 65% at age 65; reduces to 65% at age 65; reduces to 65% at age 65; 40% at age 70; 25% at age 75 40% at age 70; 25% at age 75 40% at age 70; 25% at age 75

Disability Provision Premium Waiver 60 Premium Waiver 60 Premium Waiver 60

Conversion Included Included Included

Accelerated Death Benefit Up to 75% of benefit; Up to 75% of benefit; Up to 75% of benefit; 24 month acceleration 24 month acceleration 24 month acceleration

Dependent Life Spouse $5,000; Spouse $5,000; Spouse $5,000; Child $2,000 Child $2,000 Child $2,000

AD&D Ultra®

AD&D Ultra Schedule Matches basic life benefit Matches basic life benefit Matches basic life benefit

AD&D Ultra Extra Benefits Passenger restraint use and airbag deployment, education benefit for your child and/or spouse, child care and repatriation of mortal remains.

Disability Plan Design Low Option Medium Option High Option

Monthly Benefit Flat $500; Flat $1,000; offsets are workers’ compensation, any state disability plan, No offsets and primary and family social security benefits.

Elimination Period 30 days 30 days 30 days

Definition of Disability Own Occupation: Own Occupation: First 24 months of benefits: Own Earnings loss of 20% or more. Earnings loss of 20% or more. Occupation: Earnings Loss of 20% or more; Any reasonable occupation thereafter: 40% earnings loss.

Benefit Duration 24 months 24 months 60 months

Pre-Existing Condition Limitation 3/12 3/12 3/12

Types of Disability Occupational & non-occupational Occupational & non-occupational Occupational & non-occupational

Separate Periods of Disability 15 days during elimination period 15 days during elimination period 15 days during elimination period 6 months thereafter 6 months thereafter 6 months thereafter

Mental Health/Substance Abuse Duration same as all other conditions Duration same as all other conditions Duration same as all other conditions

Waiver of Premium Included Included Included

Other Plan Provisions

Eligibility Active full-time employees Active full-time employees Active full-time employees

Rate Guarantee 1 year 1 year 1 year

Rates PEPM $8.00 $15.00 $27.00

For plan options for group size 51 and above, please consult your Aetna account executive.

Life insurance policies and disability insurance plans/policies are offered and/or underwritten by Aetna Life Insurance Company (Aetna). 37 Underwriting guidelines In business, nothing is more critical to success than the health and well-being of employees.

38 Underwriting guidelines

This material is for informational purposes only and is not intended to be all inclusive. Other policies and guidelines may apply. Note: State and federal legislation/regulations, including Small Group Reform and HIPAA, take precedence over any and all underwriting rules. Exceptions to underwriting rules require approval of the regional underwriting manager except where head underwriter approval is indicated. This information is the property of Aetna and its affiliates (“Aetna”), and may only be used or transmitted with respect to Aetna products and procedures, as specifically authorized by Aetna, in writing.

Census Data • Census data must be provided on all eligible, including Enrolled, Waivers (with spousal waivers notated), COBRA-eligible and/or State Continuation employees. Include name, date of birth, date of hire, gender, dependent status, residence zip code and employee work location zip code. • COBRA/State Continuation eligibles should be included on the census and noted as COBRA/Continuation. • New Business rating will be based on final enrollment. • 51 to 100 --Require census for retirees split by over and under 65. --New Business rating may be rerated if enrollment changes by more than +/- 10% from the initial quote enrollment projection.

Case Submission Dates • Groups with 2 to 100 eligibles must have all completed paperwork into Aetna Underwriting 5 business days prior to the requested effective date. If material is not received by this date, the effective date will be moved to the next available effective date, with a potential rate impact. • Exceptions must be approved by regional head underwriter. • Medicare Advantage sales must have all completed paperwork in to Aetna Underwriting 15 business days prior to the requested effective date. If completed paperwork is not received by this date, the effective date will be moved to the next month.

COBRA and State • COBRA coverage will be extended in accordance with federal law. Continuation Enrollees • COBRA/State Continuation continuees are not eligible for life or disability coverage. • COBRA/State Continuation continuees are required to be included and noted on the census. • The qualifying event, length, start and end dates must be provided. • 51 to 100 size groups: COBRA/State continuees cannot comprise more than 10% of the total eligible. • Employers with 20 or more employees (full- and part-time) are required to offer COBRA coverage. • Employers with fewer than 20 full-time employees (full- and part-time) are required to offer State Continuation. • Note: COBRA/State Continuation continuees are not to be included for the purpose of counting employees to determine the size of the group. Once the size of the group has been determined and it is determined that the law is applicable to the group, COBRA/State Continuation continuees can be included for coverage subject to normal underwriting guidelines.

Deductible Credit • Employees who are eligible and want to receive credit for deductible paid to prior company should submit a copy of the Explanation of Benefits (EOB) to Aetna. • This may be submitted with the group at the initial submission or with their first claim.

39 Dependent Eligibility Eligible dependents include: • Spouse or domestic partner of employee: If both husband and wife/partner work for the same company, they may enroll together or separately. • Children: --Medical and Dental: --Children are eligible as defined in plan documents in accordance with applicable state and federal laws, up age 26, regardless of student status, marital status, tax dependency or residency. --Children can only be covered under one parent’s plan when both parents work for the same company. --Grandchildren are eligible if court ordered. A copy of the court papers must be submitted. --Life: --2 to 50 eligible employees: Dependents are eligible from 14 days of age up to their 19th birthday, or up to their 23rd birthday if in school. --51 to 100 eligible employees: Contact your Aetna account executive. • AD&D or Disability: --2 to 50 eligible employees: Dependents are not eligible for AD&D or disability coverage. --51 to 100 eligible employees: Contact your Aetna account executive. • For Medical and Dental, dependents must enroll in the same benefits as the employee (participation is not required). • Employees may select coverage for eligible dependents under the Dental plan even if they select single coverage under the Medical Plan. See product-specific Life/AD&D and Disability guidelines under Product Specifications. • Individuals cannot be covered as an employee and dependent under the same plan, nor may children eligible for coverage through both parents be covered by both under the same plan.

Dual Option and • Dual option available for groups of 5 or more enrolled employees and may offer any combination of Triple Option 2 plans. • Triple option available for groups of 10 or more enrolled employees and may offer any combination of 3 plans. • All options must be from our currently marketed portfolio. • A minimum of one person must enroll in each plan. • Plans that include “51+” in the plan name are only available to groups with 51 to 100 employees. • Groups with 51 to 100 employees cannot have a combination of HSA Compatible plans with “51+” in the plan name and without “51+” in the plan name when offering dual or triple option.

Effective Date • The effective date must be the 1st or the 15th of the month. • The effective date requested by the employer may be up to 60 days in advance. • When a Medicare Advantage plan and a commercial plan are sold to an employer, the effective dates must coincide (for example, 1st of the month).

Electronic • The first month’s premium for new business can be processed via an electronic funds transfer/ACH. Funds Transfer • Once the group is issued, customers can pay their monthly premiums online or by calling an automated (EFT) phone number, 1-866-350-7644, using their checking account and routing number. There is no extra charge for this service.

40 Employee Eligibility • Eligible employees are defined as those employees who are permanent and work on a full-time basis 2 to 50 Group Size with a normal workweek of at least 30 hours. • Employer may elect to treat part-time employees who are permanent and work a normal workweek of 10 hours or more as eligible employees. • Seasonal employees are eligible employees if they work the minimum hours per week and work at least 26 weeks per calendar year. • If employer defines eligible employees at a normal workweek greater than 30 hours, Aetna will determine Small Group Medical plan eligibility based on all employees with a normal workweek of 30 hours, but will calculate participation based on the employer-defined eligibility. Maximum eligible employee workweek is 40 hours. • Coverage must be extended to all employees meeting the above conditions, unless they belong to a union class excluded as the result of a collective bargaining arrangement. While they must be included in the count in determining whether or not the group is a small employer, the employer may carve out union employees as an excluded class. • Employees are eligible to enroll in the dental plan even if they do not select medical coverage and vice versa. • Sole proprietors, partners of a partnership or independent contractors are eligible employees, provided they meet requirement to be an eligible employee. • Temporary or substitute employees are not eligible. • Life and Disability only: Employees who are both disabled and away from work on the date their insurance would otherwise become effective will become insured on the date they return to active full-time work one full day.

Retirees • Retiree coverage is available if employer currently has retiree coverage or if employer decides to offer retiree coverage and provides Aetna with documentation of the retiree plan, including eligibility requirements. • Retirees will be included with all other eligible employees for purposes of rating the group, but are not counted in the total to determine Small Group Reform. • Medicare-eligible retirees who are enrolled in an Aetna Medicare plan are eligible to enroll in Standard Dental plans in accordance with these Dental underwriting guidelines. • Coverage is available for Medicare-eligible retirees and/or active Medicare-eligibles in accordance with the Small Group Medicare underwriting guidelines. • Retirees are not eligible for Life, Disability or Voluntary Dental coverage.

Employee Eligibility • Eligible employees are those who are permanent and work on a full-time basis with a normal work 51 to 100 Group Size week of at least 25 hours, and who have met any authorized waiting period requirements.

Retirees • Retirees cannot comprise more than 10% of the group. • The retiree must be currently covered with present carrier (must be shown on the bill roster or provide a copy of the ID card). • If there were no retirees covered by the prior carrier the employee must be covered as an employee on the bill roster.

Employer Definition • Any person, firm, corporation, partnership, association or “subgroup” engaged actively in a business 50 or fewer eligible that employed an average of 50 or fewer eligible employees during the preceding calendar year, more employees of whom were employed within MAINE than in any other state. • A group is not an eligible group if there is any one other state where there are more eligible employees than are employed in MAINE and the group had coverage in that state or is eligible for guaranteed issuance of coverage in that state. • Groups with 50 or fewer eligible employees that do not meet the above definition of a small employer are not eligible for coverage.

41 Employer Eligibility • Medical plans can be offered to sole proprietorships with one or more eligible employees, partnerships or corporations. • Organizations must not be formed solely for the purpose of obtaining health coverage. • Associations, Taft-Hartley groups, professional employers organizations (PEO)/employee leasing firms and closed groups (groups that restrict eligibility through criteria other than employment) and groups where no employer/employee relationship exists are not eligible. • One employee must work a minimum of 30 hours per week. • Dental and disability have ineligible industries, which are listed separately under Product Specifications. • Dental and disability have ineligible industries, which are listed separately below. The dental ineligible list does not apply when dental is sold in combination with medical. • Groups with 51 to 100 eligible employees are not subject to Small Group Reform (SGR) and are therefore not Guaranteed Issue.

Initial Premium • The initial premium payment should be in the amount of the first month’s premium and may be in the form of a check or electronic funds transfer (EFT). • If you choose to use the EFT method, Aetna will withdraw the initial premium from the checking account when the group is approved. This is a one-time authorization for the first month’s premium only. If you supply a copy of the check, once coverage is approved you will be advised where to mail the initial premium check. • The initial premium submission is not a binder check and does not bind Aetna to provide coverage. • The initial premium submission equal to one month’s premium must accompany application. • If the request for coverage is withdrawn or denied due to business ineligibility, participation and/or contribution not met or other permissible reasons the initial premium submission will be returned to the employer. • If the initial premium submission is returned or declined for non-sufficient funds, coverage will be terminated retroactively to the effective date.

Licensed, Appointed • Only appropriately licensed agents/producers appointed by Aetna may market, present, sell and be Producers paid commission on the sale of Aetna products. • License and appointment requirements vary by state and are based on the contract state of the employer group being submitted.

Municipalities and • A township is generally a small unit that has the status and powers of local government. Townships • A municipality is an administrative entity composed of a clearly defined territory and its population, 2 to 50 Group Size and commonly denotes a city, town or village. A municipality is typically governed by a mayor and city council, or municipal council. • Underwriting requirements: --Quarterly Wage and Tax Statement (QWTS) --W2 – Elected or appointed officials and trustees “may” be eligible for group coverage based on the charter or legislation. If so, they may not be on the QWTS; rather, they may be paid via W2. In that case, obtain a copy of their prior year W2. • If elected officials are to be covered, provide a copy of the charter or contract indicating which classes or employees are to be covered, the minimum hours required to work per week to be eligible for coverage, and confirmation that coverage will be offered to all employees meeting the minimum number of required hours and that minimum participation will be maintained.

42 Newly Formed Business Newly formed businesses may be considered at the discretion of the underwriter if the following are provided: Sole Proprietor • A copy of the business license (not a professional license)

Partnership or Limited • A copy of the partnership agreement Liability Partnership

Limited Liability • A copy of the articles of organization and the operating Company agreement to include the signature page(s) of all officers

Corporation • A copy of the articles of incorporation that includes the signature page(s) of all officers (must be followed up with a copy of the statement of information within 30 days of filing with the state)

Each newly formed business must also provide: • Proof of Employer Identification Number/federal Tax Identification Number; and • Quarterly Wage and Tax statement. If not available, when will one be filed; and • The most recent two consecutive weeks worth of payroll records which includes hours worked, taxes withheld, check number and wages earned; or • A letter from the group or a CPA with the following information: --A list of all employees, to include owners, partners, officers (full time and part time) --Number of hours worked by each employee --Weekly salary for each employee --Date of hire for each employee --Whether payroll records have been established --Will a Quarterly Wage and Tax Statement be filed? Is so, when? • 51 to 100: Groups that are not subject to Guarantee Issue may require Individual Health Statements and can be declined.

PEO (Professional • 2 to 50 eligible employees: Subject to underwriting approval, groups may be considered as long as the Employer Organization) PEO provides payroll specific to one group even though the group may be reported under the PEO tax ID. • 51 to 100 eligible employees: Groups are eligible as long as they are leaving the PEO and provide a letter of intent upon sale.

Prior Aetna Coverage • Groups that have been terminated for non-payment by Aetna may require six months of premium with application and must pay all premiums still owed on the prior Aetna plan before the new plan will be issued.

43 Rates • Rates are quoted on a 4-tier structure: single, couple, employee plus child(ren), family. • Composite rates are based on final enrollment and require that: --No portion of the member’s cost sharing, including, but not limited to, copayments, deductibles and/ or coinsurance balances will be subsidized or funded by the employer, with the exception of a federally qualified Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA), whether insured or self-funded, including, but not limited to, a partially self-funded Section 105 wraparound, now or in the future; and --Employer is not funding the deductible of the quoted health plan through an HRA or HSA in excess of 50% annually. • All quotes are subject to change, based on additional information that becomes available in the quoting process and during case submission/installation, including any change in census. • If both husband and wife work for the same company and apply under one contract, rates will be based on the older adult. • If any of the information Aetna receives is determined to be incomplete or incorrect, we reserve the right to adjust rates and/or rescind the offer. • 51 to 100: New Business rating may be rerated if enrollment changes by more than +/- 10% from the initial quote enrollment projection.

Replacing Other • Provide a copy of the current billing statement that includes the account summary showing the plan is Group Coverage paid to the current premium due date. • The employer should be told not to cancel any existing medical coverage until they have been notified of approval. • 51 to 100 eligible employees --D&B must be run on all new business prospects to ensure the financial soundness of prospect. --Claims experience is required unless the prior carrier is known not to release claims experience. Medical underwriting is required; known high-cost or emergent conditions must be provided. Current rates are required from the current carrier and renewal rates should also be provided. The employer is required to have a history of staying with their carrier for several years.

Signature Dates • The Aetna Employer Application and all employee applications must be signed and dated prior to and within 90 days of the requested effective date. • All employee applications must be completed by the employee himself/herself.

44 Tax Information/ • Groups with 1 to 20 eligible employees OR 21 to 50 eligible employees WITHOUT prior coverage must Documents for 1 to 20 provide a copy of the most recent Quarterly Wage and Tax Statement (QWTS) containing the names, eligible employees OR 21 salaries, etc., of all employees of the employer group. to 50 eligible employees --Newly hired employees should be written in on the Quarterly Wage & Tax Statement. This may be WITHOUT prior coverage requested at the discretion of the underwriter. The underwriter may request payroll in questionable situations. --Employees who have terminated or work part time must be noted accordingly on the QWTS. --Reconciled QWTS must be signed and dated by the employer. Any handwritten comments added to the QWTS must be signed and dated by the employer. The underwriter may request payroll in questionable situations. • If a QWTS is not available, explain why and provide a copy of payroll records. • Seasonal industries such as lawn and garden services, concrete and paving, golf courses, farm laborers, etc., must provide four consecutive quarters of wage and tax reports to verify consistent, continuous employment of eligible employees. • An eligible employee who is a spouse of the owner who is not listed as the business owner and whose name does not appear on the QWTS, must submit one of the following: --Workers’ compensation insurance audit or evidence of waiver of benefits under Title 30-A, noting the employee’s name and duties. --Commercial General Liability Insurance Policy or equivalent that lists the employee’s name and duties. --All of the following: --Signature card from financial institution authorizing employee to sign the business checking account that is at least six months old, --A notarized affidavit from the employer, describing the duties of the employee and the average hours per week worked by the employee and that the employer is not defrauding Aetna and that the employer is aware of the consequence of committing fraud or misrepresentation, including loss of coverage and --If coverage is obtained through a producer, a notarized affidavit from the producer affirming the employer qualifies as eligible for coverage. • Churches must provide Form 941, including a copy of the payroll records with employee names, wages and hours, which must match the totals on Form 941. • Sole proprietors, partners and corporate officers not listed on the QWTS need to complete Aetna’s Small Group Proof of Eligibility form (located at https://www.aetna.com/producer/SmallGroup/ small_group.html) and submit one of the following identified documents. This list is not all inclusive. The employer may provide any other documentation to establish eligibility.

45 Tax Information / Sole Proprietor • IRS Form 1040, along with Schedule C (Form 1040) Documents for 1 to 20 • Franchise • IRS Form 1040, along with Schedule SE (Form 1040) eligible employees OR 21 • IRS Form 1040, along with Schedule F (Form 1040) to 50 eligible employees • Limited Liability • IRS Form 1040, along with Schedule K1 (Form 1065) WITHOUT prior coverage Company (operating (continued) as a sole proprietor) • Any other documentation the owner would like to provide to determine eligibility

Partner • IRS Form 1065 Schedule K-1 • Partnership • IRS Form 1120 S Schedule K-1, along with Schedule E (Form 1040) • Limited Liability • Partnership agreement, if established within two years; eligible Partnership partners must be listed on agreement • Any other documentation the owner would like to provide to determine eligibility

Corporate Officer • IRS Form 1120 S Schedule K1, along with Schedule E (Form 1040) • Limited Liability • IRS Form 1120 W (C-Corp & Personal Service Corp) Company (operating • 1040 ES (Estimated Tax) (S-Corp) as C Corp) • IRS Form 8832 (Entity classification as a corporation) • C-Corporation • W2 • Personal Service • Articles of incorporation if established within two years; corporate Corporation officers must be listed • S-Corporation • Any other documentation the owner would like to provide to determine eligibility

Tax Information/ • A QWTS is not needed if a bill roster is provided and at least 75% of the eligible employees are on the Documents for Groups prior carrier billing statement. with 21 to 50 Eligible • A copy of the current billing statement that includes the account summary and employee roster Employees WITH Prior is needed. GROUP Coverage • If no prior carrier, then a QWTS is needed and documented as noted above. • If a QWTS or prior carrier bill roster is not available, explain why and provide a copy of payroll records. The underwriter may request additional information if warranted.

46 Two or More Companies Employers who have more than one business with different Tax Identification Numbers (TINs) may be – Affiliated, Associated eligible to enroll as one group if the following are met: or Multiple Companies, • One owner has controlling interest of all businesses to be included; or Common Ownership • The owner files (or is eligible to file) an Affiliations Schedule, IRS Form 851, a combined tax return for all (2 to 50 size groups) companies to be included. If they are eligible but choose not to file Form 851, please indicate as such. A copy of the latest filed tax return must be provided; and • All businesses filed under one combined tax return must be enrolled as one group. For example, if the employer has three businesses and files all three under one combined tax return, then all three businesses must be enrolled for coverage. If the request is for only two of the three businesses to be enrolled, the group will be considered a carve-out, will not be Guarantee Issue and could be declined. • A completed Common Ownership form is submitted. • Businesses with equal controlling interest may be considered, if the owners of the company designate an individual to act on behalf of all the groups. Underwriting reserves the right to final underwriting review, and may consider common ownership on a case-by-case underwriting exception.

Example • The enrolling business (the group that is being used as the policy name), as well as the other businesses to be combined, must have the minimum number of employees required by the state. • One owner has controlling interest of all companies to be included: --Company 1 – Jim owns 75% and Jack owns 25% --Company 2 – Jim owns 55% and Jack owns 45% • Both companies can be written as one group since Jim has controlling interest in both businesses.

Two or more companies • If the companies file taxes together provide a copy of the 851 tax form. – Affiliated, Associated • If the companies do not file taxes together provide a letter on company letterhead providing or Multiple Companies, a list of each company and percent of ownership for each individual. Common Ownership • One owner must have at least 80% ownership in each company. (51 to 100 size groups) • Complete the Single Employer Plans form. The letter has to be signed by an officer of the company.

Waiting Period • At initial submission of the group, the benefit waiting period may be waived upon the employer’s request. This should be checked on the Employer Application. • The benefit waiting period for future employees may be 0, 1, 2, 3, 4, 5 or 6 months. • A change to the benefit waiting period may only be made on the plan anniversary date. • No retroactive changes will be allowed. • Two benefit waiting periods may be selected and must be consistently applied within a class of employees as defined by the employer, such as management versus non-management, hourly versus salaried, etc. • For new hires, the eligibility date will be the first day of the policy month following the waiting period. Example 1 Effective date is July 1; employees will be issued an effective date of the first of the month following the chosen waiting period.

Example 2 Effective date is July 15; employees will be issued an effective date of the fifteenth of the month following the chosen waiting period.

47 Product Specifications

Basic Life/AD&D, Packaged Life Medical Dental and Disability

Product Availability • Groups of 100 or fewer eligible 1 eligible employee • 1 eligible employee - not available employees. • Not available Life • Medical coverage may be written stand-alone or with 2 eligible employees • 2 to 9 eligible employees if sold with Medical. ancillary coverage as noted in • Standard dental plans available • 10 to 50 eligible employees if the following columns. with medical. sold with Medical or Dental. • Occupational coverage: • Voluntary dental plans not • 26 to 50 eligible employees on a A contract holder who has available. validly waived workers’ stand-alone basis. compensation under Maine 3 to 100 eligible employees • 51 to 100 contact your Aetna Law may be covered for Account Executive. • Standard and Voluntary dental occupational disease or injury. plans available with or without Must submit proof of Workers’ Packaged Life and Disability medical. Compensation coverage waiver • 2 to 50 eligible employees if • Stand-alone available. (which has been filed and packaged with Medical. accepted by the state). • Stand-alone dental has • 26 to 50 eligible employees on a The waiver would allow the ineligible Industries, which are stand-alone basis. contract holder to be covered listed separately under the SIC for occupational disease or code section of the guidelines. • 51 to 100: not available. injury if waiver has occurred • A plan sponsor cannot purchase prior to the condition, ailment Orthodontia both Life and Packaged Life and or injury as provided by the • Ortho coverage is available to Disability plans. Workers’ Compensation Act. dependent children only for • The same employer eligibility Maine state law requires groups with 10 or more eligible guidelines that apply to Medical employers to carry Workers’ employees with a minimum of will apply to Basic Term Life and Compensation coverage on 5 enrolled for Standard and Packaged Life/Disability their employees. Voluntary plans. coverage. • Plans which include “51+” in the • Product packaging rule is a plan name are only available to group-level requirement. groups with 51 to 100 Employees will be able to employees. individually elect Life, Disability • Groups with 51 to 100 or Packaged Life & Disability employees cannot have a insurance even if they do not combination of HSA elect Medical coverage. Compatible plans with “51+” in the plan name and without Disability “51+” in the plan name when • Groups are ineligible for offering dual or triple option. coverage if 60% or more of eligible employees or 60% or more of eligible payroll are for employees over 50 years old. • Conversion options are not available. • Available to employees only; dependents are not eligible. • Employees may elect Disability coverage even if they do not elect Medical coverage. • 51 to 100 contact your Aetna account executive.

48 Product Specifications

Basic Life/AD&D, Packaged Life Medical Dental and Disability

Carve Out/ • Employees covered under a • Union employees are the only • Union employees are the only Excluded Class union-sponsored plan can be class of employees that may class of employees that may excluded as a class. However, be excluded. However, union be excluded. However, union union employees are included employees are included in the employees are included in the in the total count of eligible total count of eligible total count of eligible employees in determining the employees in determining the employees in determining the case size. case size. case size. • Carve-outs are permitted, • Management carve-outs are • Management carve-outs are provided the minimum not permitted. not permitted. participation and eligibility requirements are met.

Employer Contribution • 2 to 50: No minimum Standard plans • 2 to 9 eligible employees — employer or employee • Employers must contribute at 100% of the total cost of the contribution required. least 25% of the total cost of Basic Term Life plan (excluding • 51 to 100: Employer must the plan or 50% of the cost of Optional Dependent Term). contribute at least 50% of the employee-only coverage. • 10 to 50 eligible employees — total cost of the plan or 75% of at least 50% of the total cost the cost of employee-only Voluntary plans of the plans (excluding coverage. • 3 to 9 eligible employees - Optional Dependent Term). • Coverage can be denied based the group contribution can • 51 to 100 contact your Aetna on inadequate contributions. be from zero to 49% of the account executive. cost of the employee-only • Coverage can be denied based coverage. on inadequate contributions. • 10 to 100 eligible employees - employee pay all plans. The employer cannot contribute to the cost of the employee rate.

Standard and Voluntary • Coverage can be denied based on inadequate contributions.

49 Product Specifications

Basic Life/AD&D, Packaged Life Medical Dental and Disability

Late Applicants An employee or dependent who enrolls for coverage more than 31 days (60 days for newborns) from the date first eligible or 31 days of the qualifying event is considered a late enrollee. Applicants without a qualifying life event (that is, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.) are subject to the Late Entrant guidelines as noted below. Voluntary cancellation of coverage is NOT a qualifying event. For example, if a spouse is covered through his/her employer and voluntarily cancels the coverage, it is not a qualifying event to be added to the other spouse’s plan. The spouse who cancelled the coverage must wait until the next plan anniversary date to be eligible to be added. • Late applicants without a • An employee or dependent may • Late applicants will be deferred qualifying life event (that is, enroll at any time; however, to the next plan anniversary marriage, divorce, newborn coverage is limited to date of the group and may child, adoption, loss of spousal preventive & diagnostic reapply for coverage 30 days coverage, etc.) are not allowed services for the first 12 months. prior to the anniversary date. and will be deferred to the No coverage for most basic and • The applicant will be required to next plan anniversary date of major services for first 12 complete an individual health the group and must reapply months (24 months for statement/questionnaire and for coverage 30 days prior to orthodontics). provide Evidence of Insurability the group anniversary date. • Late Entrant provision does (EOI). • Late applicants will be not apply to enrollees under enrolled as of the date the age 5. individual requests coverage • Dental Late Entrant is not unless the effective date applicable to the DMO. requested is more than 31 days prior to Aetna’s receipt of the application. In that case, the effective date will be 31 days prior to Aetna’s receipt of the application.

Live/Work Situs • Live or work allowed as long as • Live or work allowed as long as • Not applicable. either the work zip or the either the work zip or the residence zip is within the residence zip is within the network situs area (CT and network situs area (CT and ME). ME). • 60-mile radius • 60-mile radius

Option Sales • All plans must meet • All dental plans must be • Must be written on a full or participation rules. Other offered on a full-replacement primary replacement basis. insurance offered by the same basis. employer is not a valid waiver. • No other employer-sponsored dental plan can be offered.

50 Product Specifications

Basic Life/AD&D, Packaged Life Medical Dental and Disability

Out-of-State/ • Any employee located in ME or • Out-of-state employees must • Employees are eligible for Situs Employees CT but not residing in an be enrolled in a PPO Dental Basic Term Life and Packaged Aetna Health Network Only plan if available; otherwise, an Life/Disability. and/or PPO network will be indemnity dental plan. enrolled in an indemnity benefits plan. • Any active employee who lives and works in a state other than within the group situs area (CT and ME) is considered an out-of-state employee. Out-of-state employees residing in a PPO network will be enrolled in a PPO plan. Out-of-state employees not residing in a PPO network will be enrolled in an indemnity benefits plan. • Louisiana residents: Employees residing in Louisiana are required to have a separate plan quoted and sold based on Louisiana rates and benefits. These employees are still underwritten as part of the group; however, the plans and rates for the LA members will not be based on where the employer is located. This will require a Louisiana Employer Application Employee Application to be completed.

51 Product Specifications

Basic Life/AD&D, Packaged Life Medical Dental and Disability

Participation • Coverage must be offered to Noncontributory plans Noncontributory plans all employees who meet • 100% participation is required, • 100% participation is required conditions to be an eligible excluding those with other for all noncontributory plans. employee, unless they belong qualifying dental coverage. to a union class excluded as Contributory plans the result of a collective Contributory plans • 2-9: 100% participation bargaining arrangement and Standard Dental plans therefore covered elsewhere. • 10-50: 75% participation • 2 to 3 eligible employees — • 51 to 100: Contact your Aetna Noncontributory plans 100% participation is account executive. • 100% participation is required, excluding those with required, excluding all valid other qualifying existing Stand-alone Life waivers. dental coverage. • 26 to 50 eligible employees - • 4 to 9 eligible employees — 75% participation is required. Contributory plans: 75% participation is required, • 51 to 100 eligible employees - • 2 to 50: 75% participation excluding those with other contact your Aetna account excluding valid waivers, qualifying existing dental executive. rounding down, must enroll in coverage. A minimum of 50% Aetna’s plan. of total eligible employees All plans • Valid waivers include spousal/ must enroll in the Dental plan. • Employees may elect Basic parental group coverage, • 10 to 100 eligible employees Term Life or Packaged Life/ Medicare, Champus/ChampVA, — 30% participation of total Disability insurance even if military coverage, retiree eligibles excluding those with they do not elect medical coverage or association other qualifying dental coverage. However, the group coverage. Individual coverage coverage. must meet the required is a valid waiver. Voluntary Dental plans participation percentage. • Employees with other If not, then Basic Term Life/ coverage and/or who are • 3 to 100 eligible employees Disability will be declined for waiving the employer’s plan — 30% participation, the group. excluding those with other must sign a waiver verifying • COBRA and state enrollees are qualifying existing dental other coverage or no not eligible. coverage. coverage. • Retirees are not eligible. • If an employee declines • A minimum of 3 must enroll. • Coverage can be denied based coverage because the on inadequate participation. employee has other coverage, Stand-alone Dental any dependents of that 2 to 50 eligible employees employee who are not eligible • 75% participation, excluding under the employee’s other those with other qualifying coverage are eligible for existing dental coverage. coverage under the small group health plan. • A minimum of 50% of total eligible employees must enroll • 51 to 100: 75% of employees in the dental plan. excluding those covered under a spouse’s group health 51 to 100 eligible employees benefits plan, Medicare, or • 30% participation of total Medicaid must enroll in the eligibles excluding those with Aetna plan, but not less than other qualifying dental 50% of all eligible employees coverage. regardless of spousal and other waivers.

52 Product Specifications

Basic Life/AD&D, Packaged Life Medical Dental and Disability

Participation All plans Standard and Voluntary (Continued) • Dependent participation is • Employees may select not required. coverage for eligible • Coverage can be denied based dependents under the dental on inadequate participation. plan even if they elected single coverage on the medical plan, or vice versa. • Coverage can be denied based on inadequate participation.

Plan Change • Plan anniversary date only. • Dental plans must be • Packaged Life/Disability must Group Level requested 5 days prior to the be requested 30 days prior to desired effective date. the desired effective date. • The future renewal date of the • Non-packaged plans are only change will be the same as the available on the plan medical plan anniversary date. anniversary date. • The future renewal date of the change will be the same as the medical plan anniversary date.

Plan Change • Employees are not eligible to • Employees are not eligible to • Employees are not eligible to Employee Level change plans until the group’s change plans until the group’s change plans until the group’s open enrollment period, which open enrollment period, which open enrollment period, which is upon their annual renewal is upon their annual renewal. is upon their annual renewal (except for qualified Special • Freedom of Choice - (except for qualified Special Enrollment events). May change from DMO to PPO Enrollment events). and vice versa at any time but must be received in Aetna underwriting by the 15th to be effective the next month.

53 Product Specifications

Medical • Underwriting will use a variety of tools, including Dun & Bradstreet, to verify a group’s industry code Standard Industrial and classify the business correctly. Classification Code (SIC) • All industries eligible.

Dental • All industries are eligible if sold with Medical. Standard Industrial • The following industries are not eligible when Dental is sold stand-alone or packaged only with Life. Classification Code (SIC) 7319-7319 Advertising, Miscellaneous 7800-7999 Amusement, Recreation & Entertainment 8600-8699 Associations & Trusts 5511-5599 Auto Dealerships 7231-7241 Beauty & Barber Shops 7331-7338 Direct Mailing, Secretarial 7361-7363 Employment Agencies 8700-8799 Engineering & Mgmt Services 7000-7099 Hotels 9721-9721 International Affairs 3911-3915 Jewelry Manufacturing 8100-8199 Legal 8000-8059 Medical Groups 8071-8099 Medical Groups 7389-7389 Miscellaneous Business Services 7379-7379 Miscellaneous Computer Services 7692-7699 Miscellaneous Repair 8999-8999 Miscellaneous Services 5271-5271 Mobile Home Dealers 4111-4121 Passenger Transportation 7221-7221 Photo Studios 7384-7384 Photofinishing Labs 6500-6799 Real Estate 7251-7299 Repairs, Cleaning, Personal Svc 5800-5899 Restaurants 8211-8299 Schools, Libraries, Education 0761-0783 Seasonal Employees 7381-7382 Security Sys. Armored Cars 8800-8899 Service-Private Households 8300-8499 Social Services - Museums, Art Galleries, Botanical Gardens 7631-7631 Watch, Clock & Jewelry Repair

54 Product Specifications

Basic Life/AD&D, • Basic Term Life Only - all industries are eligible. Packaged Life and • Disability Only or Packaged Life/Disability - the following industries are not eligible. Disability • 51 to 100 size groups - contact your Aetna Account Executive for an ineligible SIC list. Standard Industrial 3291-3292 Asbestos Products Classification Code (SIC) 7500-7599 Automotive Repairs/Services 8010-8043 Doctors Offices, Clinics 2892-2899 Explosives, Bombs & Pyrotechnics 3480-3489 Fire Arms & Ammunition 5921 Liquor Stores 8600-8699 Membership Associations 1000-1499 Mining 7800–7999 Motion Picture/ Amusement & Recreation 9999 Non-classified Establishments 3310-3329 Primary Metal Industries 6531 Real Estate - Agents 6211 Security Brokers 7381 Service - Detective Services 8800-8899 Service - Private Household

55 Dental Only

Coverage Standard 2 to 9 and Voluntary 3 to 100 eligible employees Waiting Period • PPO and indemnity plans - For major and orthodontic services employees must be an enrolled member of the employer’s plan for 1 year before becoming eligible. • DMO - there is no waiting period. • Discount plans do not qualify as previous coverage. • Future hires - waiting period applies regardless if takeover for Voluntary 3 to 100 eligible employees. • Virgin group (no prior coverage) - the waiting periods apply to employees at case inception as well as any future hires. • Takeover/replacement cases (prior coverage) - you must provide a copy of the last billing statement and schedule of benefits in order to provide credit. If a group’s prior coverage did not lapse more than 90 days prior, the waiting periods are waived. In order for the waiting period to be waived, the group must have had a dental plan in place that covered major (and ortho, if applicable) immediately preceding our takeover of the business. Example: Prior major coverage but no ortho coverage. Aetna plan has coverage for both major and ortho. The Waiting Period is waived for major services but not for ortho services.

Standard 10 to 100 eligible employees • No waiting period.

Open Enrollment An “open” enrollment is a period when any employee can elect to join the dental plan without penalty, regardless if they previously declined coverage during the first 31 days of initial eligibility. • Open enrollments are prohibited except for Standard plans with 10 to 100 eligible employees. For Standard plans employees/dependents who do not enroll when initially eligible are now eligible to enroll during a subsequent open enrollment period without being subject to the late entrant provision. • Voluntary plans and Standard plans with 2 to 9 eligible employees - An employee or dependent can enroll at any time but is subject to the Dental Late Entrant provision if enrollment occurs other than within 31 days of first becoming eligible unless a qualifying life event has occurred or the enrollee is less than age 5.

Reinstatement (applies • Members once enrolled who have previously terminated their coverage by discontinuing their to Voluntary plans only) contributions may not re-enroll for a period of 24 months. All coverage rules will apply from the new effective date including, but not limited to, the Coverage Waiting Period.

56 Life and Disability ONLY (2 to 50 eligible employees)

Job Classification • Varying levels of coverage based on job classifications are available for groups with 10 or more lives. (Position) schedules • Up to 3 separate classes are allowed (with a minimum requirement of 3 employees in each class). • Items such as probationary periods must be applied consistently within a class of employee. • The benefit for the class with the richest benefit must not be greater than five times the benefit of the class with the lowest benefit even if only two classes are offered. For example, a schedule may be structured as follows:

Basic Term Packaged Life Position/Job Class Life Amount Disability & Disability

Executives $50,000 Flat $500 High Option

Managers, Supervisors $20,000 Flat $300 Medium Option

All other Employees $10,000 Flat $200 Low Option

Guaranteed • Aetna provides certain amounts of life insurance to all timely entrants without requiring an employee Issue Coverage to answer any medical questions. These insurance amounts are called “Guaranteed Issue.” • Employees wishing to obtain increased insurance amounts will be required to submit Evidence of Insurability which means they must complete a medical questionnaire and may be required to provide medical records. • On-time enrollees who do not meet the requirements of Evidence of Insurability will receive the Guaranteed Issue life amount. • Late enrollees must qualify for the entire amount and are not guaranteed any coverage.

Continuity of Coverage • The employee will not lose coverage due to a change in carriers. This protects employees who are not (no loss/no gain) actively at work during a change in insurance carriers. • If an employee is not actively at work, Aetna will waive the actively-at-work requirement and provide coverage, except no benefits are payable if the prior plan is liable.

Evidence of EOI is required when one or more of the following conditions exist: Insurability (EOI) 1. Life insurance coverage amounts requested are above the Guaranteed Standard Issue Limit. 2. Late Entrant - coverage is not requested within 31 days of eligibility for contributory coverage. 3. New coverage is requested during the anniversary period. 4. Coverage is requested outside of the employer’s anniversary period due to qualifying life event (that is, marriage, divorce, newborn child, adoption, loss of spousal coverage, etc.). 5. Reinstatement or restoration of coverage is requested. 6. Dependent coverage option was initially refused by employee but requested later. The dependent would be considered a late entrant and subject to EOI, and may be declined for medical reasons. 7. Requesting life or disability at the individual level and they are a late enrollee even if enrolling on the case anniversary date. Late enrollees are not eligible for the Guarantee Issue limit. Example: Group has $50,000 life with $20,000 Guarantee Issue limit. Late enrollee enrolling for $50,000 would not automatically get the $20,000. Since the applicant is late, he or she must medically qualify for the entire $50,000.

57 Limitations and exclusions

Medical Aetna Open Choice PPO and Traditional Choice plans These plans do not cover all health care expenses and include Services and supplies that are generally not covered include, exclusions and limitations. Members should refer to their plan but are not limited to: documents to determine which health care services are covered • All medical or hospital services not specifically covered in, and to what extent. The following is a partial list of services and or which are limited or excluded in the plan documents supplies that are generally not covered. However, your plan • Charges related to any eye surgery mainly to correct documents may contain exceptions to this list based on state refractive errors mandates or the plan design or rider(s) purchased. • Cosmetic surgery, including breast reduction Aetna Health Network Only (HNOnly) plan • Custodial care Services and supplies that are generally not covered include, • Dental care and X-rays but are not limited to: • Donor egg retrieval • All medical and hospital services not specifically covered in, • Experimental and investigational procedures or which are limited or excluded by your plan documents, • Hearing aids including costs of services before coverage begins and after • Immunizations for travel or work coverage terminates • Infertility services, including, but not limited to, artificial • Cosmetic surgery insemination and advanced reproductive technologies such • Custodial care as IVF, ZIFT, GIFT, ICSI and other related services, unless • Dental care and dental X-rays specifically listed as covered in your plan documents • Donor egg retrieval • Nonmedically necessary services or supplies • Experimental and investigational procedures (except for • Orthotics coverage for medically necessary routine patient care costs for • Over-the-counter medications and supplies members participating in a cancer clinical trial) • Reversal of sterilization • Hearing aids • Services for the treatment of sexual dysfunction or • Home births inadequacies, including therapy, supplies or counseling • Immunizations for travel or work • Special duty nursing • Implantable drugs and certain injectable drugs including injectable infertility drugs • Infertility services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services unless specifically listed as covered in your plan documents • Nonmedically necessary services or supplies • Orthotics • Over-the-counter medications and supplies • Radial keratotomy or related procedures • Reversal of sterilization • Services for the treatment of sexual dysfunction or inadequacies including therapy, supplies or counseling • Special duty nursing • Therapy or rehabilitation other than those listed as covered in the plan documents

These plans do not cover all health care expenses and include exclusions and limitations. Employers and members should refer to their plan documents to determine which health care services are covered and to what extent. 58 Pre-existing Conditions Exclusion Provision Dental, AD&D Ultra and Disability These plans impose a pre-existing conditions exclusion, The Dental, AD&D Ultra and Disability plans include limitations, which may be waived in some circumstances (that is, creditable exclusions and charges or services that these plans do not cover. coverage) and may not be applicable. A pre-existing conditions For a complete listing of all limitations and exclusions or charges exclusion means that if the member has a medical condition and services that are not covered, please refer to your Aetna before coming to the plan, the member might have to wait a group plan documents. Limitations, exclusions and charges or certain period of time before the plan will provide coverage for services may vary by state or group size. that condition. This exclusion applies only to conditions for which medical advice, diagnosis or treatment was recommended Dental or received or for which the individual took prescribed drugs within six months prior to the enrollment date. Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician Generally, this period ends the day before coverage becomes or dentist. The plan covers only those services and supplies that effective. However, if the member was in a waiting period for are medically necessary. Charges for the following services or coverage, the six-month period ends on the day before the supplies are limited or may be excluded: waiting period begins. The exclusion period, if applicable, may last up to 12 months from the first day of coverage, or, if the • Dental services or supplies that are primarily used to alter, member was in a waiting period, from the first day of the improve or enhance appearance waiting period. • Experimental services, supplies or procedures If the member had prior creditable coverage within 180 days • Treatment of any jaw joint disorder, such as temporomandibular immediately before the date enrolled under the plan, then the joint disorder pre-existing conditions exclusion in the plan, if any, will • Replacement of lost, missing or stolen appliances and certain be waived. damaged appliances If the member had no prior creditable coverage within the • Those services that Aetna defines as not necessary for the 180 days prior to the enrollment date (either because the diagnosis, care or treatment of a condition involved member had no prior coverage or because there was more than • Specific service limitations: a 180-day gap from the date the prior coverage terminated to --Oral exams (2 routine and 2 problem-focused per year) the enrollment date), we will apply the plan’s pre-existing • All plans: conditions exclusion. --Bitewing X-rays (1 set per year) In order to reduce or possibly eliminate the exclusion period --Complete series X-rays (1 set every 3 years) based on creditable coverage, the member should provide --Cleanings (2 per year) Aetna with a copy of any Certificates of Creditable Coverage. --Flouride (1 per year; children under 16) Please contact Aetna Member Services at 1-888-802-3862 for PPO & TC or 1-866-529-2517 for HNOnly 2 to 50 groups and --Sealants (1 treatment per tooth; every 3 years on permanent 1-877-350-2217 for HNOnly 51 to 100 groups for assistance in molars; children under 16) obtaining a Certificate of Creditable Coverage from the prior --Scaling and root planning (4 quadrants every 2 years) carrier or with any questions on the information noted above. --Osseous surgery (1 per quadrant every 3 years) The pre-existing conditions exclusion does not apply to • All other limitations and exclusions in your plan documents pregnancy nor to a child under the age of 19. Note: For late enrollees, coverage will be delayed until the plan’s next open Employee and Dependent Life Insurance: enrollment; the pre-existing exclusion will be applied from The plan may not pay a benefit for deaths caused by suicide, the individual’s effective date of coverage. while sane or insane, or from an intentionally self-inflicted injury, within two years from the effective date of the person’s coverage. If death occurs after two years of the effective date but within two years of the date that any increase in coverage becomes effective, no death benefit will be payable for any such increased amount.

59 AD&D Ultra® Disability Not all events that may be ruled accidental are covered by Disability coverage also does not cover any disability that: this plan. No benefits are payable for a loss caused or • Is due to an occupational illness or occupational injury except contributed to by: in the case of sole proprietors or partners who cannot be • Air or space travel. This does not apply if a person is a covered by workers’ compensation. passenger, with no duties at all, on an aircraft being used only • Is due to insurrection, rebellion, or taking part in a riot or civil to carry passengers (with or without cargo). commotion. • Bodily or mental infirmity. • Is due to intentionally self-inflicted injury (while sane or insane). • Commission of or attempt to commit a criminal act. • Is due to war or any act of war (declared or not declared). • Illness, ptomaine or bacterial infection.* • Results from your commission of, or attempt to commit a • Inhalation of poisonous gases. criminal act. • Intended or accidental contact with nuclear or atomic energy • Results from a motor vehicle accident caused by operating the by explosion and/or release. vehicle while you are under the influence of alcohol. A motor • Ligature strangulation resulting from autoerotic asphyxiation. vehicle accident will be deemed to be caused by the use of • Intentionally self-inflicted injury. alcohol if it is determined that at the time of the accident you were operating the motor vehicle while under the influence of • Medical or surgical treatment.* alcohol at a level which meets or exceeds the level at which • Third-degree burns resulting from sunburn. intoxication would be presumed under the laws of the state • Use of alcohol. where the accident occurred.) If the accident occurs outside of • Use of drugs, except as prescribed by a physician. the United States, intoxication will be presumed if the person’s • Use of intoxicants. blood alcohol level meets or exceeds .08 grams per deciliter. • Use of alcohol or intoxicants or drugs while operating any form Disability coverage does not cover any disability on any day that of a motor vehicle whether or not registered for land, air or you are confined in a penal or correctional institution for water use. A motor vehicle accident will be deemed to be conviction of a criminal act or other public offense. You will not caused by the use of alcohol, intoxicants or drugs if it is be considered to be disabled, and no benefits will be payable. determined that at the time of the accident you or your No benefit is payable for any disability that occurs during the covered dependent were: first 12 months of coverage and is due to a pre-existing --Operating the motor vehicle while under the influence of condition for which the member was diagnosed, treated or alcohol is at a level which meets or exceeds the level at which received services, treatment, drugs or medicines three months intoxication would be presumed under the laws of the state prior to the coverage effective date. where the accident occurred. If the accident occurs outside of the United States, intoxication will be presumed if the person’s blood alcohol level meets or exceeds .08 grams per deciliter; or --Operating the motor vehicle while under the influence of an intoxicant or illegal drug; or --Operating the motor vehicle while under the influence of a prescription drug in excess of the amount prescribed by the physician; or --Operating the motor vehicle while under the influence of an over-the-counter medication taken in an amount above the dosage instructions. • Suicide or attempted suicide (while sane or insane). • War or any act of war (declared or not declared).

*These do not apply if the loss is caused by: -An infection that results directly from the injury. -Surgery needed because of the injury. The injury must not be one that is excluded by the terms of this section. 60

This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Rates and benefits may vary by location. Health/dental benefits, health/dental insurance, life and disability insurance plans/policies contain exclusions and limitations. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Plan features and availability may vary by location and group size. Aetna HealthFund HRAs are subject to employer-defined use and forfeiture rules and are unfunded liabilities of your employer. Fund balances are not vested benefits. Investment services are independently offered through HealthEquity, Inc. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Plan for Your Health is a public education program from Aetna and The Financial Planning Association. Providers are independent contractors and not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Not all health, dental and disability services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. The Aetna Personal Health Record should not be used as the sole source of information about the member’s medical history. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. www.aetna.com

©2012 Aetna Inc. 64.10.302.1-ME (6/12)